CCRI Nursing 1010 HESI 1 NCLEX Questions
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1. The nurse hears a client calling out for 16. Answer: 3
help, hurries down the hallway to the Rationale: The occurrence report should con-
client's room, and finds the client lying tain a factual description of the
on the floor. The nurse performs an as- occurrence, any injuries experienced by those
sessment, assists the client back to bed, involved, and the outcome of the
notifies the primary health care provider, situation. The correct option is the only one
and completes an occurrence report. that describes the facts as observed by
Which statement should the nurse doc- the nurse. Options 1, 2, and 4 are interpreta-
ument on the occurrence report? tions of the situation and are not factual
information as observed by the nurse.
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to
get out of bed.
2. A client is brought to the emergency 17. Answer: 3
department by emergency medical ser- Rationale: In general, there are two situations
vices (EMS) after being hit by a car. Thein which informed consent of an
name of the client is unknown, and the adult client is not needed. One is when an
client has sustained a severe head in- emergency is present and delaying
jury and multiple fractures and is uncon-treatment for the purpose of obtaining in-
scious. An emergency craniotomy is re- formed consent would result in injury or
quired. Regarding informed consent for death to the client. The second is when the
the surgical procedure, which is the bestclient waives the right to give informed
action? consent. Option 1 will delay emergency treat-
ment, and option 2 is inappropriate.
1. Obtain a court order for the surgical Although option 4 may be pursued, it is not the
procedure. best action because it delays
2. Ask the EMS team to sign the informed necessary emergency treatment.
consent.
3. Transport the victim to the operating
, CCRI Nursing 1010 HESI 1 NCLEX Questions
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room for surgery.
4. Call the police to identify the client and
locate the family.
3. The nurse has just assisted a client backAnswer: 1
to bed after a fall. The nurse and pri- Rationale: After a client's fall, the nurse must
mary health care provider have assessed frequently reassess the client,
the client and have determined that the because potential complications do not always
client is not injured. After completing the
appear immediately after the fall. The
occurrence report, the nurse should im- client's fall should be treated as private infor-
plement which action next? mation and shared on a "need to know"
basis. Communication regarding the event
1. Reassess the client. should involve only the individuals
2. Conduct a staff meeting to describe participating in the client's care. An occurrence
the fall. report is a problem-solving
3. Contact the nursing supervisor to up- document; however, its completion is not doc-
date information regarding umented in the nurse's notes. If the
the fall. nursing supervisor has been made aware of
4. Document in the nurse's notes that an the occurrence, the supervisor will
occurrence report was contact the nurse if status update is necessary.
completed.
4. The nurse arrives at work and is told to Answer: 2
report (float) to the intensive care unit Rationale: Floating is an acceptable practice
(ICU) for the day because the ICU is un- used by hospitals to solve
derstaffed and needs additional nurses understaffing problems. Legally, the nurse
to care for the clients. The nurse has nev- cannot refuse to float unless a union
er worked in the ICU. The nurse should contract guarantees that nurses can work only
take which best action? in a specified area or the nurse can
prove the lack of knowledge for the perfor-
1. Refuse to float to the ICU based on lack mance of assigned tasks. When
of unit orientation. encountering this situation, the nurse should
, CCRI Nursing 1010 HESI 1 NCLEX Questions
Study online at https://quizlet.com/_8afvt9
2. Clarify the ICU client assignment with set priorities and identify potential
the team leader to ensure areas of harm to the client. That is why clarify-
that it is a safe assignment. ing the client assignment with the team
3. Ask the nursing supervisor to review leader to ensure that it is a safe one is the best
the hospital policy on option. The nursing supervisor is
floating. called if the nurse is expected to perform tasks
4. Submit a written protest to nursing that he or she cannot safely perform.
administration, and then call Submitting a written protest and calling the
the hospital lawyer. hospital lawyer is a premature action.
5. The nurse who works on the night shift Answer: 3
enters the medication room and finds Rationale: Nurse practice acts require report-
a coworker with a tourniquet wrapped ing impaired nurses. The board of
around the upper arm. The coworker is nursing has jurisdiction over the practice of
about to insert a needle, attached to a nursing and may develop plans for
syringe containing a clear liquid, into the treatment and supervision of the impaired
antecubital area. Which is the most ap- nurse. This occurrence needs to be
propriate action by the nurse? reported to the nursing supervisor, who will
then report to the board of nursing and
1. Call security. other authorities, such as the police, as re-
2. Call the police. quired. The nurse may call security if a
3. Call the nursing supervisor. disturbance occurs, but no information in the
4. Lock the coworker in the medication question supports this need, and so
room until help is obtained. this is not the appropriate action. Option 4 is
an inappropriate and unsafe action.
6. A hospitalized client tells the nurse that Answer: 4
an instructional directive is being pre- Rationale: Instructional directives (living wills)
pared and that the lawyer will be bring- are required to be in writing and
ing the document to the hospital today signed by the client. The client's signature
for witness signatures. The client asks must be witnessed by specified
the nurse for assistance in obtaining a individuals or notarized. Laws and guidelines
, CCRI Nursing 1010 HESI 1 NCLEX Questions
Study online at https://quizlet.com/_8afvt9
witness to the will. Which is the most regarding instructional directives
appropriate response to vary from state to state, and it is the responsi-
the client? bility of the nurse to know the laws.
Many states prohibit any employee, including
1. "I will sign as a witness to your signa- the nurse of a facility where the client
ture." is receiving care, from being a witness. Option
2. "You will need to find a witness on your 2 is nontherapeutic and not a helpful
own." response. The nurse should seek the assis-
3. "Whoever is available at the time will tance of the nursing supervisor.
sign as a witness for you."
4. "I will call the nursing supervisor to
seek assistance regarding
your request."
7. The nurse has made an error in docu- Answer: 2, 3, 4, 5
mentation of the dose administered of Rationale: Electronic health records (EHR) will
an opioid pain medication in the client's have a time date stamp that
record. The nurse draws 1 mg from the indicates an amendment has been entered. If
vial and another registered nurse (RN) the nurse makes an error in the MAR,
witnesses wasting of the the nurse should follow agency policies to cor-
remaining 1 mg. When scanning the rect the error. In the MAR, the nurse
medication, the nurse entered into the can click on the entry (usually right-click) and
medication administration record (MAR) modify it to reflect the corrected
that 2 mg of hydromorphone was admin- information. Since this is an opioid medica-
istered instead of the actual dose admin- tion, the nurse should obtain a
istered, which was 1 mg. The cosignature from the RN who witnessed the
nurse should take which action(s) to cor- wasting of the excess medication, to
rect the error in the MAR? Select all that validate that 1 mg, rather than 2 mg, was giv-
apply. en. A nurse's note should be used to
detail the event and the corrections made, and
1. Complete and file an occurrence re- the nurse's name and title will be stamped on
port. the entry in the EHR. An occurrence report is
Study online at https://quizlet.com/_8afvt9
1. The nurse hears a client calling out for 16. Answer: 3
help, hurries down the hallway to the Rationale: The occurrence report should con-
client's room, and finds the client lying tain a factual description of the
on the floor. The nurse performs an as- occurrence, any injuries experienced by those
sessment, assists the client back to bed, involved, and the outcome of the
notifies the primary health care provider, situation. The correct option is the only one
and completes an occurrence report. that describes the facts as observed by
Which statement should the nurse doc- the nurse. Options 1, 2, and 4 are interpreta-
ument on the occurrence report? tions of the situation and are not factual
information as observed by the nurse.
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to
get out of bed.
2. A client is brought to the emergency 17. Answer: 3
department by emergency medical ser- Rationale: In general, there are two situations
vices (EMS) after being hit by a car. Thein which informed consent of an
name of the client is unknown, and the adult client is not needed. One is when an
client has sustained a severe head in- emergency is present and delaying
jury and multiple fractures and is uncon-treatment for the purpose of obtaining in-
scious. An emergency craniotomy is re- formed consent would result in injury or
quired. Regarding informed consent for death to the client. The second is when the
the surgical procedure, which is the bestclient waives the right to give informed
action? consent. Option 1 will delay emergency treat-
ment, and option 2 is inappropriate.
1. Obtain a court order for the surgical Although option 4 may be pursued, it is not the
procedure. best action because it delays
2. Ask the EMS team to sign the informed necessary emergency treatment.
consent.
3. Transport the victim to the operating
, CCRI Nursing 1010 HESI 1 NCLEX Questions
Study online at https://quizlet.com/_8afvt9
room for surgery.
4. Call the police to identify the client and
locate the family.
3. The nurse has just assisted a client backAnswer: 1
to bed after a fall. The nurse and pri- Rationale: After a client's fall, the nurse must
mary health care provider have assessed frequently reassess the client,
the client and have determined that the because potential complications do not always
client is not injured. After completing the
appear immediately after the fall. The
occurrence report, the nurse should im- client's fall should be treated as private infor-
plement which action next? mation and shared on a "need to know"
basis. Communication regarding the event
1. Reassess the client. should involve only the individuals
2. Conduct a staff meeting to describe participating in the client's care. An occurrence
the fall. report is a problem-solving
3. Contact the nursing supervisor to up- document; however, its completion is not doc-
date information regarding umented in the nurse's notes. If the
the fall. nursing supervisor has been made aware of
4. Document in the nurse's notes that an the occurrence, the supervisor will
occurrence report was contact the nurse if status update is necessary.
completed.
4. The nurse arrives at work and is told to Answer: 2
report (float) to the intensive care unit Rationale: Floating is an acceptable practice
(ICU) for the day because the ICU is un- used by hospitals to solve
derstaffed and needs additional nurses understaffing problems. Legally, the nurse
to care for the clients. The nurse has nev- cannot refuse to float unless a union
er worked in the ICU. The nurse should contract guarantees that nurses can work only
take which best action? in a specified area or the nurse can
prove the lack of knowledge for the perfor-
1. Refuse to float to the ICU based on lack mance of assigned tasks. When
of unit orientation. encountering this situation, the nurse should
, CCRI Nursing 1010 HESI 1 NCLEX Questions
Study online at https://quizlet.com/_8afvt9
2. Clarify the ICU client assignment with set priorities and identify potential
the team leader to ensure areas of harm to the client. That is why clarify-
that it is a safe assignment. ing the client assignment with the team
3. Ask the nursing supervisor to review leader to ensure that it is a safe one is the best
the hospital policy on option. The nursing supervisor is
floating. called if the nurse is expected to perform tasks
4. Submit a written protest to nursing that he or she cannot safely perform.
administration, and then call Submitting a written protest and calling the
the hospital lawyer. hospital lawyer is a premature action.
5. The nurse who works on the night shift Answer: 3
enters the medication room and finds Rationale: Nurse practice acts require report-
a coworker with a tourniquet wrapped ing impaired nurses. The board of
around the upper arm. The coworker is nursing has jurisdiction over the practice of
about to insert a needle, attached to a nursing and may develop plans for
syringe containing a clear liquid, into the treatment and supervision of the impaired
antecubital area. Which is the most ap- nurse. This occurrence needs to be
propriate action by the nurse? reported to the nursing supervisor, who will
then report to the board of nursing and
1. Call security. other authorities, such as the police, as re-
2. Call the police. quired. The nurse may call security if a
3. Call the nursing supervisor. disturbance occurs, but no information in the
4. Lock the coworker in the medication question supports this need, and so
room until help is obtained. this is not the appropriate action. Option 4 is
an inappropriate and unsafe action.
6. A hospitalized client tells the nurse that Answer: 4
an instructional directive is being pre- Rationale: Instructional directives (living wills)
pared and that the lawyer will be bring- are required to be in writing and
ing the document to the hospital today signed by the client. The client's signature
for witness signatures. The client asks must be witnessed by specified
the nurse for assistance in obtaining a individuals or notarized. Laws and guidelines
, CCRI Nursing 1010 HESI 1 NCLEX Questions
Study online at https://quizlet.com/_8afvt9
witness to the will. Which is the most regarding instructional directives
appropriate response to vary from state to state, and it is the responsi-
the client? bility of the nurse to know the laws.
Many states prohibit any employee, including
1. "I will sign as a witness to your signa- the nurse of a facility where the client
ture." is receiving care, from being a witness. Option
2. "You will need to find a witness on your 2 is nontherapeutic and not a helpful
own." response. The nurse should seek the assis-
3. "Whoever is available at the time will tance of the nursing supervisor.
sign as a witness for you."
4. "I will call the nursing supervisor to
seek assistance regarding
your request."
7. The nurse has made an error in docu- Answer: 2, 3, 4, 5
mentation of the dose administered of Rationale: Electronic health records (EHR) will
an opioid pain medication in the client's have a time date stamp that
record. The nurse draws 1 mg from the indicates an amendment has been entered. If
vial and another registered nurse (RN) the nurse makes an error in the MAR,
witnesses wasting of the the nurse should follow agency policies to cor-
remaining 1 mg. When scanning the rect the error. In the MAR, the nurse
medication, the nurse entered into the can click on the entry (usually right-click) and
medication administration record (MAR) modify it to reflect the corrected
that 2 mg of hydromorphone was admin- information. Since this is an opioid medica-
istered instead of the actual dose admin- tion, the nurse should obtain a
istered, which was 1 mg. The cosignature from the RN who witnessed the
nurse should take which action(s) to cor- wasting of the excess medication, to
rect the error in the MAR? Select all that validate that 1 mg, rather than 2 mg, was giv-
apply. en. A nurse's note should be used to
detail the event and the corrections made, and
1. Complete and file an occurrence re- the nurse's name and title will be stamped on
port. the entry in the EHR. An occurrence report is
