Grand Canyon University BIO 201
HESI - Fundamentals
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N330: Week 2 (NCLEX Practice Ques... CAPSTONE DQ 1 medical terms Rule of
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When turning an immobile bedridden client without B
assistance, which action by the nurse best ensures client Rationale: Because the nurse can only stand on one side of the bed, bed rails
safety? should be up on the opposite side to ensure that the client does not fall out of
A. Securely grasp the client's arm and leg. bed. Option A can cause client injury to the skin or joint. Options C and D are
B. Put bed rails up on the side of bed opposite from the useful techniques while turning a client but have less priority in terms of safety
nurse. than use of the bed rails.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
The nurse identifies a potential for infection in a client B
with partial-thickness (second-degree) and full-thickness Rationale: Careful handwashing technique is the single most effective intervention
(third-degree) burns. What intervention has the highest for the prevention of contamination to all clients. Option A reverses the
priority in decreasing the client's risk of infection? hypovolemia that initially accompanies burn trauma but is not related to
A. Administration of plasma expanders decreasing the proliferation of infective organisms. Options C and D are
B. Use of careful handwashing technique recommended by various burn centers as possible ways to reduce the chance of
C. Application of a topical antibacterial cream infection. Option B is a proven technique to prevent infection.
D. Limiting visitors to the client with burns
The nurse is aware that malnutrition is a common problem A
among clients served by a community health clinic for the Rationale: Long-term protein deficiency is required to cause significantly lowered
homeless. Which laboratory value is the most reliable serum albumin levels. Albumin is made by the liver only when adequate amounts
indicator of chronic protein malnutrition? of amino acids (from protein breakdown) are available. Albumin has a long half-
A. Low serum albumin level life, so acute protein loss does not significantly alter serum levels. Option B is a
B. Low serum transferrin level serum protein with a half-life of only 8 to 10 days, so it will drop with an acute
C. High hemoglobin level protein deficiency. Options C and D are not clinical measures of protein
D. High cholesterol level malnutrition.
,In completing a client's preoperative routine, the nurse C
finds that the operative permit is not signed. The client Rationale: The surgeon should be informed immediately that the permit is not
begins to ask more questions about the surgical signed. It is the surgeon's responsibility to explain the procedure to the client and
procedure. Which action should the nurse take next? obtain the client's signature on the permit. Although the nurse can witness an
A. Witness the client's signature to the permit. operative permit, the procedure must first be explained by the health care
B. Answer the client's questions about the surgery. provider or surgeon, including answering the client's questions. The client's
C. Inform the surgeon that the operative permit is not questions should be addressed before the permit is signed.
signed and the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any
questions before the anesthesia is administered.
The nurse is assessing several clients prior to surgery. B
Which factor in a client's history poses the greatest threat Rationale:
for complications to occur during surgery? Anticoagulants increase the risk for bleeding during surgery, which can pose a
A. Taking birth control pills for the past 2 years threat for the development of surgical complications. The health care provider
B. Taking anticoagulants for the past year should be informed that the client is taking these drugs. Although clients who take
C. Recently completing antibiotic therapy birth control pills may be more susceptible to the development of thrombi, such
D. Having taken laxatives PRN for the last 6 months problems usually occur postoperatively. A client with option C or D is at less of a
surgical risk than with option B.
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the
A. Place the chair parallel to the bed, with its back toward nurse a wide base of support while stabilizing the client's knees when assisting to
the head of the bed and assist the client in moving to the a standing position. The chair should be placed at a 45-degree angle to the bed,
chair. with the back of the chair toward the head of the bed. Clients should never be
B. With the nurse's feet spread apart and knees aligned lifted under the axillae; this could damage nerves and strain the nurse's back. The
with the client's knees, stand and pivot the client into the client should be instructed to use the arms of the chair and should never place his
chair. or her arms around the nurse's neck; this places undue stress on the nurse's neck
C. Assist the client to a standing position by gently lifting and back and increases the risk for a fall.
upward, underneath the axillae.
D. Stand beside the client, place the client's arms around
the nurse's neck, and gently move the client to the chair.
Which step(s) should the nurse take when administering A, B
ear drops to an adult client? (Select all that apply.) Rationale: The correct answers (A and B) are the appropriate administration of ear
A. Place the client in a side-lying position. drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton
B. Pull the auricle upward and outward. ball should be placed in the outermost canal (D). The auricle is pulled down and
C. Hold the dropper 6 cm above the ear canal. back for a child younger than 3 years of age, but not an adult (E).
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
The nurse is instructing a client in the proper use of a B
metered-dose inhaler. Which instruction should the nurse Rationale: The medication should be inhaled through the mouth simultaneously
provide the client to ensure the optimal benefits from the with compression of the inhaler. This will facilitate the desired destination of the
drug? aerosol medication deep in the lungs for an optimal bronchodilation effect.
A. "Fill your lungs with air through your mouth and then Options A, C, and D do not allow for deep lung penetration.
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."
, A 20-year-old female client with a noticeable body odor D
has refused to shower for the last 3 days. She states, "I Rationale: Because a shower is most beneficial for the client in terms of hygiene,
have been told that it is harmful to bathe during my the client should receive teaching first, respecting any personal beliefs such as
period." Which action should the nurse take first? cultural or spiritual values. After client teaching, the client may still choose option
A. Accept and document the client's wish to refrain from A or B. Brochures reinforce the teaching.
bathing.
B. Offer to give the client a bed bath, avoiding the
perineal area.
C. Obtain written brochures about menstruation to give
to the client.
D. Teach the importance of personal hygiene during
menstruation with the client.
While reviewing the side effects of a newly prescribed A
medication, a 72-year-old client notes that one of the Rationale: Option A offers an open-ended question most relevant to the client's
side effects is a reduction in sexual drive. Which is the statement. Option B does not offer the client the opportunity to express concerns.
best response by the nurse? Options C and D are even less relevant to the client's statement.
A. "How will this affect your present sexual activity?"
B. "How active is your current sex life?"
C. "How has your sex life changed as you have become
older?"
D. "Tell me about your sexual needs as an older adult."
The nurse is using the Glasgow Coma Scale to perform a .A
neurologic assessment. A comatose client winces and Rationale: The client has demonstrated a purposeful response to pain, which
pulls away from a painful stimulus. Which action should should be documented as such. Response to painful stimulus is assessed after
the nurse take next? response to verbal stimulus, not before. There is no indication for placing the
A. Document that the client responds to painful stimulus. client on seizure precautions. Reporting decorticate posturing to the health care
B. Observe the client's response to verbal stimulation. provider is nonpurposeful movement.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care
provider
The nurse plans to administer diazepam, 4 mg IV push, to B
a client with severe anxiety. How many milliliters should Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
the nurse administer? (Round to the nearest tenth.)
A. 0.2 mL
B. 0.8 mL
C. 1.25 mL
D. 2.0 mL
The nurse prepares to insert a nasogastric tube in a client A, D
with hyperemesis who is awake and alert. Which Rationale:
intervention(s) is(are) correct? (Select all that apply.) (A and D) are the correct steps to follow during nasogastric intubation. Only the
A. Place the client in a high Fowler position. unconscious or obtunded client should be placed in a left side-lying position (B).
B. Help the client assume a left side-lying position. The tube should be measured from the tip of the nose to behind the ear and then
C. Measure the tube from the tip of the nose to the from behind the ear to the xiphoid process (C). The neck should only be extended
umbilicus. back prior to the tube passing the pharynx and then the client should be
D. Instruct the client to swallow after the tube has passed instructed to position the neck forward (E).
the pharynx.
E. Assist the client in extending the neck back so the tube
may enter the larynx.
HESI - Fundamentals
Save
Students also studied
N330: Week 2 (NCLEX Practice Ques... CAPSTONE DQ 1 medical terms Rule of
100 terms 59 terms 79 terms 125 term
StudyPride Preview red_roses800 Preview sals456 Preview Tah
When turning an immobile bedridden client without B
assistance, which action by the nurse best ensures client Rationale: Because the nurse can only stand on one side of the bed, bed rails
safety? should be up on the opposite side to ensure that the client does not fall out of
A. Securely grasp the client's arm and leg. bed. Option A can cause client injury to the skin or joint. Options C and D are
B. Put bed rails up on the side of bed opposite from the useful techniques while turning a client but have less priority in terms of safety
nurse. than use of the bed rails.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
The nurse identifies a potential for infection in a client B
with partial-thickness (second-degree) and full-thickness Rationale: Careful handwashing technique is the single most effective intervention
(third-degree) burns. What intervention has the highest for the prevention of contamination to all clients. Option A reverses the
priority in decreasing the client's risk of infection? hypovolemia that initially accompanies burn trauma but is not related to
A. Administration of plasma expanders decreasing the proliferation of infective organisms. Options C and D are
B. Use of careful handwashing technique recommended by various burn centers as possible ways to reduce the chance of
C. Application of a topical antibacterial cream infection. Option B is a proven technique to prevent infection.
D. Limiting visitors to the client with burns
The nurse is aware that malnutrition is a common problem A
among clients served by a community health clinic for the Rationale: Long-term protein deficiency is required to cause significantly lowered
homeless. Which laboratory value is the most reliable serum albumin levels. Albumin is made by the liver only when adequate amounts
indicator of chronic protein malnutrition? of amino acids (from protein breakdown) are available. Albumin has a long half-
A. Low serum albumin level life, so acute protein loss does not significantly alter serum levels. Option B is a
B. Low serum transferrin level serum protein with a half-life of only 8 to 10 days, so it will drop with an acute
C. High hemoglobin level protein deficiency. Options C and D are not clinical measures of protein
D. High cholesterol level malnutrition.
,In completing a client's preoperative routine, the nurse C
finds that the operative permit is not signed. The client Rationale: The surgeon should be informed immediately that the permit is not
begins to ask more questions about the surgical signed. It is the surgeon's responsibility to explain the procedure to the client and
procedure. Which action should the nurse take next? obtain the client's signature on the permit. Although the nurse can witness an
A. Witness the client's signature to the permit. operative permit, the procedure must first be explained by the health care
B. Answer the client's questions about the surgery. provider or surgeon, including answering the client's questions. The client's
C. Inform the surgeon that the operative permit is not questions should be addressed before the permit is signed.
signed and the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any
questions before the anesthesia is administered.
The nurse is assessing several clients prior to surgery. B
Which factor in a client's history poses the greatest threat Rationale:
for complications to occur during surgery? Anticoagulants increase the risk for bleeding during surgery, which can pose a
A. Taking birth control pills for the past 2 years threat for the development of surgical complications. The health care provider
B. Taking anticoagulants for the past year should be informed that the client is taking these drugs. Although clients who take
C. Recently completing antibiotic therapy birth control pills may be more susceptible to the development of thrombi, such
D. Having taken laxatives PRN for the last 6 months problems usually occur postoperatively. A client with option C or D is at less of a
surgical risk than with option B.
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the
A. Place the chair parallel to the bed, with its back toward nurse a wide base of support while stabilizing the client's knees when assisting to
the head of the bed and assist the client in moving to the a standing position. The chair should be placed at a 45-degree angle to the bed,
chair. with the back of the chair toward the head of the bed. Clients should never be
B. With the nurse's feet spread apart and knees aligned lifted under the axillae; this could damage nerves and strain the nurse's back. The
with the client's knees, stand and pivot the client into the client should be instructed to use the arms of the chair and should never place his
chair. or her arms around the nurse's neck; this places undue stress on the nurse's neck
C. Assist the client to a standing position by gently lifting and back and increases the risk for a fall.
upward, underneath the axillae.
D. Stand beside the client, place the client's arms around
the nurse's neck, and gently move the client to the chair.
Which step(s) should the nurse take when administering A, B
ear drops to an adult client? (Select all that apply.) Rationale: The correct answers (A and B) are the appropriate administration of ear
A. Place the client in a side-lying position. drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton
B. Pull the auricle upward and outward. ball should be placed in the outermost canal (D). The auricle is pulled down and
C. Hold the dropper 6 cm above the ear canal. back for a child younger than 3 years of age, but not an adult (E).
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
The nurse is instructing a client in the proper use of a B
metered-dose inhaler. Which instruction should the nurse Rationale: The medication should be inhaled through the mouth simultaneously
provide the client to ensure the optimal benefits from the with compression of the inhaler. This will facilitate the desired destination of the
drug? aerosol medication deep in the lungs for an optimal bronchodilation effect.
A. "Fill your lungs with air through your mouth and then Options A, C, and D do not allow for deep lung penetration.
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."
, A 20-year-old female client with a noticeable body odor D
has refused to shower for the last 3 days. She states, "I Rationale: Because a shower is most beneficial for the client in terms of hygiene,
have been told that it is harmful to bathe during my the client should receive teaching first, respecting any personal beliefs such as
period." Which action should the nurse take first? cultural or spiritual values. After client teaching, the client may still choose option
A. Accept and document the client's wish to refrain from A or B. Brochures reinforce the teaching.
bathing.
B. Offer to give the client a bed bath, avoiding the
perineal area.
C. Obtain written brochures about menstruation to give
to the client.
D. Teach the importance of personal hygiene during
menstruation with the client.
While reviewing the side effects of a newly prescribed A
medication, a 72-year-old client notes that one of the Rationale: Option A offers an open-ended question most relevant to the client's
side effects is a reduction in sexual drive. Which is the statement. Option B does not offer the client the opportunity to express concerns.
best response by the nurse? Options C and D are even less relevant to the client's statement.
A. "How will this affect your present sexual activity?"
B. "How active is your current sex life?"
C. "How has your sex life changed as you have become
older?"
D. "Tell me about your sexual needs as an older adult."
The nurse is using the Glasgow Coma Scale to perform a .A
neurologic assessment. A comatose client winces and Rationale: The client has demonstrated a purposeful response to pain, which
pulls away from a painful stimulus. Which action should should be documented as such. Response to painful stimulus is assessed after
the nurse take next? response to verbal stimulus, not before. There is no indication for placing the
A. Document that the client responds to painful stimulus. client on seizure precautions. Reporting decorticate posturing to the health care
B. Observe the client's response to verbal stimulation. provider is nonpurposeful movement.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care
provider
The nurse plans to administer diazepam, 4 mg IV push, to B
a client with severe anxiety. How many milliliters should Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
the nurse administer? (Round to the nearest tenth.)
A. 0.2 mL
B. 0.8 mL
C. 1.25 mL
D. 2.0 mL
The nurse prepares to insert a nasogastric tube in a client A, D
with hyperemesis who is awake and alert. Which Rationale:
intervention(s) is(are) correct? (Select all that apply.) (A and D) are the correct steps to follow during nasogastric intubation. Only the
A. Place the client in a high Fowler position. unconscious or obtunded client should be placed in a left side-lying position (B).
B. Help the client assume a left side-lying position. The tube should be measured from the tip of the nose to behind the ear and then
C. Measure the tube from the tip of the nose to the from behind the ear to the xiphoid process (C). The neck should only be extended
umbilicus. back prior to the tube passing the pharynx and then the client should be
D. Instruct the client to swallow after the tube has passed instructed to position the neck forward (E).
the pharynx.
E. Assist the client in extending the neck back so the tube
may enter the larynx.
