CCRI Nursing 1010 HESI 1 NCLEX Questions with Complete Solutions
The nurse hears a client calling out for help, hurries down the hallway to
the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?
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. Correct Answer-16. Answer: 3
Rationale: The occurrence report should contain a factual description of the
occurrence, any injuries experienced by those involved, and the outcome
of the
situation. The correct option is the only one that describes the facts as observed by
the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual
information as observed by the nurse.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best
action?
1. Obtain a court order for the surgical procedure.
2. Ask the EMS team to sign the informed consent.
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family. Correct Answer-17. Answer: 3
Rationale: In general, there are two situations in which informed consent
of an
adult client is not needed. One is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury or
death to the client. The second is when the client waives the right to give
informed
consent. Option 1 will delay emergency treatment, and option 2 is inappropriate.
Although option 4 may be pursued, it is not the best action because it delays
necessary emergency treatment.
The nurse has just assisted a client back to bed after a fall. The nurse and
primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence
report, the nurse should implement which action next? 1. Reassess the client.
2. Conduct a staff meeting to describe the fall.
3. Contact the nursing supervisor to update information regarding
the fall.
4. Document in the nurse's notes that an occurrence report was
completed. Correct Answer-Answer: 1
Rationale: After a client's fall, the nurse must frequently reassess the client,
because potential complications do not always appear immediately after the fall. The
client's fall should be treated as private information and shared on a "need to know"
basis. Communication regarding the event should involve only the individuals
participating in the client's care. An occurrence report is a problem-
solving
document; however, its completion is not documented in the nurse's notes. If the
nursing supervisor has been made aware of the occurrence, the supervisor will
contact the nurse if status update is necessary.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?
1. Refuse to float to the ICU based on lack of unit orientation.
2. Clarify the ICU client assignment with the team leader to ensure
that it is a safe assignment.
3. Ask the nursing supervisor to review the hospital policy on
floating.
4. Submit a written protest to nursing administration, and then call
the hospital lawyer. Correct Answer-Answer: 2
Rationale: Floating is an acceptable practice used by hospitals to solve
understaffing problems. Legally, the nurse cannot refuse to float unless a
union
contract guarantees that nurses can work only in a specified area or the nurse can
prove the lack of knowledge for the performance of assigned tasks. When
encountering this situation, the nurse should set priorities and identify potential
areas of harm to the client. That is why clarifying the client assignment with the team
leader to ensure that it is a safe one is the best option. The nursing supervisor is
called if the nurse is expected to perform tasks that he or she cannot safely perform.
The nurse hears a client calling out for help, hurries down the hallway to
the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?
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. Correct Answer-16. Answer: 3
Rationale: The occurrence report should contain a factual description of the
occurrence, any injuries experienced by those involved, and the outcome
of the
situation. The correct option is the only one that describes the facts as observed by
the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual
information as observed by the nurse.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best
action?
1. Obtain a court order for the surgical procedure.
2. Ask the EMS team to sign the informed consent.
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family. Correct Answer-17. Answer: 3
Rationale: In general, there are two situations in which informed consent
of an
adult client is not needed. One is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury or
death to the client. The second is when the client waives the right to give
informed
consent. Option 1 will delay emergency treatment, and option 2 is inappropriate.
Although option 4 may be pursued, it is not the best action because it delays
necessary emergency treatment.
The nurse has just assisted a client back to bed after a fall. The nurse and
primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence
report, the nurse should implement which action next? 1. Reassess the client.
2. Conduct a staff meeting to describe the fall.
3. Contact the nursing supervisor to update information regarding
the fall.
4. Document in the nurse's notes that an occurrence report was
completed. Correct Answer-Answer: 1
Rationale: After a client's fall, the nurse must frequently reassess the client,
because potential complications do not always appear immediately after the fall. The
client's fall should be treated as private information and shared on a "need to know"
basis. Communication regarding the event should involve only the individuals
participating in the client's care. An occurrence report is a problem-
solving
document; however, its completion is not documented in the nurse's notes. If the
nursing supervisor has been made aware of the occurrence, the supervisor will
contact the nurse if status update is necessary.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?
1. Refuse to float to the ICU based on lack of unit orientation.
2. Clarify the ICU client assignment with the team leader to ensure
that it is a safe assignment.
3. Ask the nursing supervisor to review the hospital policy on
floating.
4. Submit a written protest to nursing administration, and then call
the hospital lawyer. Correct Answer-Answer: 2
Rationale: Floating is an acceptable practice used by hospitals to solve
understaffing problems. Legally, the nurse cannot refuse to float unless a
union
contract guarantees that nurses can work only in a specified area or the nurse can
prove the lack of knowledge for the performance of assigned tasks. When
encountering this situation, the nurse should set priorities and identify potential
areas of harm to the client. That is why clarifying the client assignment with the team
leader to ensure that it is a safe one is the best option. The nursing supervisor is
called if the nurse is expected to perform tasks that he or she cannot safely perform.
