HESI Fundamentals Resource Guide|Complete 100% Solution guide and Questions and Answers_ A+ Guide Updated Fall 2025/26.

HESI Fundamentals Resource Guide Activity & Sleep Knowledge Check  Activity intolerance – How do you assess for activity intolerance? What strategies would you implement for a patient at risk for activity intolerance?  Elimination –What is your role as the nurse with a patient on the bedside commode? What if they are in a bedside chair and either have to use the bathroom or have an accident. What is your role?  Foot Care – Who needs foot care? What is your role in foot care?  Heat application - When applying heat to a patient, what must you assess?  Insomnia - For someone who can’t sleep, what assessments should you do? What is the cause of the insomnia?  Mouth Care – Who needs it? How do you provide it for the patient that can do it themselves vs. those that are unable? What about those in a coma (think about body position)? What about a ventilator?  Oral care NG Tube – How do you provide oral care to a patient with an NG tube?  Position change – When do patients need to change positions? How would you as the nurse assist or change the patients position?  Sleep Apnea – What is sleep apnea? What are the side effects of having sleep apnea? For those with sleep apnea, how and why are they oxygenated?  Sleep & Exercise – What is the correlation between the two?  Sleep – What is insomnia? How might you help a patient with insomnia get to sleep? Think least invasive first (back rub, dark quiet room) – medication is the last resort.  Sleep Pattern – Why might sleep be disturbed? What can you do to help restore one’s sleep pattern?  Soaking feet – What is the reason for soaking feet? What do you need to assess? What about water temperature? What about drying feet? Toenails? Who is at risk for having feet issues? In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderlyA. is to be expected and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep. Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again. The nurse should implement (D) because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Pre-medicate the client with an analgesic. B. Inform the client of the plan for moving to the chair. C. Obtain and place a portable commode by the bed. D. Ask the client to push the IV pole to the chair. E. Clamp the indwelling catheter. F. Assess the client's blood pressure. The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client'scooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. Asepsis Knowledge Check  Droplet precautions – What type of mask is required for droplet precautions? What if you are not fitted for this type of mask?  MRSA - Order of Procedures – Think about a patient in isolation for MRSA. What if you have to give an IV medication, an oral medication, change a wound, and suction the patient - what order would you go in?  Infection control – What is biohazardous waste, and how might you handle this to prevent infection? What if the patient is in isolation?  Risk for Infection – What are infection risks? What type of patients are at greater risk for infections? What can you as the nurse do to prevent infections?  Sterile Gloving package – Know how to properly open and don/doff sterile gloves.Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety-degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first. Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field. Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D).Communication Knowledge Check  Communication – What is SBAR? What goes into each section of SBAR? When would you use SBAR?  Interpreter – What is the role of the interpreter? When will you need one?  Objective data – What is it? Know the difference between objective and subjective data?  Open ended questions – What are they? When do you ask them? The nurse is caring for a pregnant patient who is nervous about having a cesarean delivery. The nurse says, “Don’t worry. You may not need a cesarean section.” Which action is the nurse performing? A. Acting defensively B. Advising the patient C. Giving false reassurance D. Giving a generalized response The information indicates the nurse is giving false reassurance to the patient (“Don’t worry”), which discounts the patient’s feelings. The nurse should encourage the patient to further discuss any fears and teach about precautions that may reduce the need for cesarean section. If the patient questioned the nurse’sresponse, it may cause the nurse to act defensively (saying, for example, “I work very hard”). When the nurse directly gives advice (for example, starting a statement with “you should…”) without assessing the patient first, it shows that the nurse is giving inappropriate advice. A generalized response is a cliched or stereotyped statement of opinion (like “Keep your chin up”) by the nurse that may be interpreted as demonstrating a lack of engagement or interest. During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private. Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings. When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A. There is no reason to be so angry. B. Why do I need to leave your room? C. What is concerning you this morning? D. Let me call the client advocate for you. (C) is an open-ended question that encourages the client to discuss personal feelings. (A) devalues the client and hinders further communication. Acting defensively and asking why questions such as (B) are likely to elicit more anger and block communication. By deferring to the client advocate (D), the nurse fails to even address the client's feelings of anger and exasperation. A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. Your children are old enough to help you make decisions about their futures. B. The social worker can tell you about placement alternatives for your children. C. Tell me what you would like to see happen with your children in the future. D. You have just received bad news, and you need some time to adjust to it.The nurse should first assess what the client desires (C). (A) is somewhat judgmental and attempts to solve the problem for the client without eliciting the client's feelings. Though a referral to the social worker (B) may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news (D), but the nurse should first provide support and assess what the client wants to see happen with her children. Cultural/SpiritualA client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. Eye contact is a culturallyinfluenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated. When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices. Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D)An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you. The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured. An African American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension. Different cultural groups often have their own terms for health conditions. African American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain). The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition. Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintainhealth and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice. A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator. A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred. A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life. Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented but does not have the priority of (B). A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A. Use distraction techniques during times of spiritual stress and crisis.B. Reassure the client that his faith will be regained with time and support. C. Consult with the staff chaplain and ask that the chaplain visit with the client. D. Use reflective listening techniques when the client expresses spiritual doubts. The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A. May I ask your daughter to help you with your personal hygiene? B. I will ask one of the female nurses to bathe you. C. A staff member on the next shift will help you. D. I will keep you draped and hand you the supplies as you need them. Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task (B). (A and D) are less respectful of the client's cultural and spiritual preferences. (C) delays the client's care. A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use. The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading.A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client. Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the family's needs to care for the client and are not the best ways to cope with the nurse's frustration. Although (D) may be an option, examining one's cultural differences allows the nurse to cope, empathize, and implement culturally specific interventions pertaining to the needs of the client and the family. Death & Grief Knowledge Check  End of Life – As a nurse, what questions would you ask if a patient were to question end of life care, options? Hint: Make sure the patient is fully informed.  End of Life Choices – What is the role of the RN in end-of-life choices?  Grief – Anticipatory – What is this? How will you as the nurse help the patient/family with anticipatory grief?  Grief – How would you recognize and analyze cues for a patient who is grieving?  Hospice care – What is Hospice? What education might you provide the patient regarding hospice? Who is hospice appropriate for?  Hospice – Teach – As a hospice nurse, what might you provide education on? Who would you teach?A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request. The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented.At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you. (C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem. In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Request hospice care for the client. B. Report the client's acuity level to the nursing supervisor. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent. The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D). Elimination Bowel Knowledge Check  Assessment – Why would we assess feces? What are we looking for? What would you document?  Constipation – How would you assess a patient for constipation? Using the nursing process, how would you treat a patient with constipation?  Diarrhea - What are some nursing interventions that you can provide for a patient with diarrhea?  Enemas – What are they, how do you give them, what is the goal of an enema? How will you know it is effective?  Impaction removal – Patients that have fecal impaction, how can it be removed? Look updigital fecal impaction removal. What are the risks?  Stool Specimen – How do you collect a stool specimen? What might a specimen be looking for?An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure. Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D). On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate. Prune juice is a natural laxative that stimulates peristalsis and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation but will not help relieve the client's constipation. Defecation isnot painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance. Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit. While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down. During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C). The nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa. The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may causeincreased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B). Elimination Bladder Knowledge Check  24 Hour Urine – What is a 24-hour urine specimen? How do you properly collect this specimen? What is this specimen for?  Bladder Rupture – What is a bladder rupture? What is the role of the nurse with a patient experiencing urinary retention and a bladder rupture? Is this patient going to have a normal urinary catheter?  Dehydration – What would you see if someone is dehydrated? What would their vitals look like? What about skin? What about urine? What might you note if the dehydration was resolving.  Urinary catheter removal – What is the technique of removing a catheter? What education would you give a patient prior to removing and after removing a urinary catheter? During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit.Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution. To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective finding? A. Complains of inability to empty bladder. B. Temperature of 99.8° F and pulse of 108. C. Post-voided residual volume of 750 ml. D. Specimen collection for culture and sensitivity. The nurse should document the client's complaints (A) as subjective data--symptoms only the client can describe. (B) should be documented as objective data, which is collected via the nurse's observation. (C and D) are documented as intervention results. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves?A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution. To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A. Ensure that the client's perineal area is cleansed twice a day. B. Maintain accurate documentation of the fluid intake and output. C. Encourage frequent ambulation if allowed or regular turning if on bedrest. D. Obtain a prescription for removal of the catheter as soon as possible. The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection but are of less priority than (D) in reducing the risk of urosepsis. Ethical/Legal Knowledge Check  Document Method – What are the various documentation methods?  Electronic documentation – What is this? What do you need to know about electronic documentation? What happens if the power goes out?  Good Samaritan – What is the Good Samaritan Law, and how are you protected?  HIPAA - interpreter – What is the role of the interpreter? What does HIPAA have to do with the interpreter?  HIPAA Young Adult – What are the rules of HIPAA when it comes to a child? What about a young adult?  Legal tort – What is this? Why do you need to know about these?An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred. The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D). An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth admission assessment D. Initiate the nursing care plan E. Evaluate the patient’s technique for using MDI’s Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs’ position description or job descriptions, the employing facility’s policies and procedures, and legal aspects of care such as the states’ legal scopes of practice for nurses, nursing assistants and other members of the nursing team. Option A: The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement, and evaluate care under the direct supervision and guidance of the registered nurse. Option B: Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member. Option C: Scopes of practice should be considered prior to the assignment of care. All states have scopes of practice for advanced nursepractitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians. Option D: The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. Some staff members may possess greater expertise than others. Option E: Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN. The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment. The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D). A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions. When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience. According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C). A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration. Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained. A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A. A quasi-intentional tort because a similar mistake can happen to anyone. B. Failure to respect client autonomy to choose based on intentional tort law. C. Assault and battery with deliberate intent to deviate from the consent form. D. An unintentional tort because the client benefited from having the myelogram.The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice. A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical. What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students. B. Notify the student's clinical instructor of the situation. C. Ask the student if permission was obtained from the client. D. Explain that the records are hospital property and may not be removed. The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B)so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information. The nurse overhears the healthcare provider explaining to the client that the tumor removed was nonmalignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? A. Healthcare provider. B. Client's family. C. Case manager. D. Chief of staff. The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth--this may be at the family's request (A). (B, C, and D) may be indicated, but first the nurse should confer with the healthcare provider to obtain all needed information. Which statement best describes durable power of attorney for health care? A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.B. The healthcare decisions made by another person designated by the client are not legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding. The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time. F&E Knowledge Check  Fluid volume deficit – What is the role of sodium in the body? What is fluid volume deficit? How does sodium play into this?  Hyperkalemia – What is it? What signs and symptoms might you see in a patient with hyperkalemia? What assessments would you make on this patient?  Water Intoxication – what is this? What might you assess in a patient with water intoxication? What is the corrective action?What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area. Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Transferrin. B. Prealbumin. C. Serum albumin. D. Urine urea nitrogen. Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of ironbinding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C). When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A. Confirm the finding by further assessing the client for jugular vein distention. B. Offer the client high protein snacks between regularly scheduled mealtimes. C. Continue the planned nursing interventions to restore the client's fluid volume. D. Change the plan of care to include a nursing diagnosis of impaired skin integrity. Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume (C). Jugular vein distention (A) is a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid volume deficit. Changes in the client's skin integrity are not evident (D). A client is demonstrating a positive Chvostek's sign. What action should the nurse take? A. Observe the client's pupil size and response to light. B. Ask the client about numbness or tingling in the hands. C. Assess the client's serum potassium level.D. Restrict dietary intake of calcium-rich foods. A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium. Hygiene Knowledge Check  Hand hygiene – What is it? What are the various types, and when can they be used?  Handwashing – Home teaching – How would you teach a patient how to wash their hands at home? Adult vs. pediatric  Hygiene – Oral care – Think about providing oral care to various patients – consider the following: dentures, patients in a coma, patients on a ventilator What client statement indicates to the nurse that the client requires assistance with bathing?A. I wasn't able to pack a bag before I left for the hospital. B. I don't understand why I'm so weak and tired. C. I only bathe every other day. D. I left my eyeglasses at home. Bathing often makes a client feel weak, and if a client is already feeling weak (B), assistance is required during the bathing process to ensure the client's safety. (A and C) do not pose safety issues. Although (D) may pose a safety issue, further assessment is needed to determine if this in fact poses a safety issue for the client. Medication Administration Knowledge Check  Barbiturate – What type of medications are barbiturates? What do you as the nurse need to do if a barbiturate is refused by the patient?  Ear drops – teaching – Review the technique for instilling ear drops. How would you teach this to a patient. What patient education would you provide?  Med Dose – Resource – Who or what are your options when it comes to verifying a medication?  Injection Skills – Know what types of injections are given where (locations) and the technique.  Syringe size – How do you determine which size syringe to use?The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner. Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide aroundtheclock dosing. Food may alter absorption of the medication (D)A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses. A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has anti-inflammatory actions, (D) is not indicated. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record. The nurse took the correct action and should document the events that occurred in the nurses' notes (C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's medical record and should be placed in the chart, (D) when no longer current. Mobility Knowledge Check  Assess mobility – How do you assess mobility?  Immobility – What type of care do you provide to someone who is immobile? What other considerations do you need to make? What would you assess?  Mobility – Crutch walking – What are you as the nurse looking for? What are some safety concerns with someone using crutches?  Log rolling – what is this? Why do we do this? What type of patient would need log rolling?  ROM Exercises – What are ROM exercises? How would you as the nurse help the patient with these?An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. While instructing a male client's wife in the performance of passive range-ofmotion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion. The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide