HESI SAUNDERS ONLINE NCLEX MODULE 5
|Questions with 100% Correct Answers
TEST TAKING STRATEGIES:
Note the strategic word "first." Think about the classification of each medication to determine
its action. This will help you answer correctly. Also note that atorvastatin and zolpidem are
comparable or alike in that they are administered at bedtime. Next, recalling the action of
levothyroxine will direct you to this option. Review the medications in the options and their
method of administration if you had difficulty with this question.
A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action
reflects the use of evidence-based practice in the care of the client?
a. Keeping the door to the client's room closed
b. Using a surgical mask when entering the client's room
c. Placing the client in a semiprivate room with a cohort client
d. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all
times - ✔️✔️a. Keeping the door to the client's room closed
Rationale:
Evidence-based practice is an approach to client care in which the nurse integrates the client's
preferences, clinical expertise, and the best research evidence to deliver quality care.
Pulmonary tuberculosis is a respiratory infection that is transmitted to others by way of the
airborne route. The door to the client's room must be kept closed to prevent the transmission
of the infection via the airborne route. The remaining options do not reflect evidence-based
practice. An N95 or HEPA respirator (not a surgical mask) must be worn by the nurse on
entering the room. It is not necessary for the client to wear a mask. Airborne precautions
require the use of a private room.
TEST TAKING STRATEGIES:
Read each option carefully, focusing on the subject, evidence-based practice. Recall the
definition of evidence-based practice and recall that tuberculosis is transmitted by way of the
,airborne route. This will direct you to the correct option. Review the concept of evidence-based
practice if you had difficulty with this question
A man who is visiting his wife in a long-term care facility for people with Alzheimer disease
collapses and is transported to a hospital. The client remains unconscious, and testing reveals
that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the
wife's care facility report to the hospital health care provider that the client has no other family
members and that his wife is mentally incompetent. What information regarding do-not-
resuscitate (DNR) orders does the nurse remember?
a. That a DNR order may be written by a client's health care provider
b. That everything possible must be done if the client stops breathing
c. That medications only may be given to the client if the client stops breathing
d. That life support measures will have to be implemented if the client stops breathing - ✔️✔️a.
That a DNR order may be written by a client's health care provider
Rationale:
In a situation in which a client has no family members who can provide permission for
treatment, the health care provider may write a DNR order if he or she is reasonably and
medically certain that resuscitation would be futile. Therefore the other options are inaccurate.
TEST TAKING STRATEGIES:
Focus on the data in the question, and note that the client is terminally ill and has no family
members other than a wife who is mentally incompetent. Eliminate the comparable or alike
options that indicate that resuscitation measures will be instituted. Next eliminate the option
containing the closed-ended word "only." Review the ethical and legal issues related to DNR
orders if you had difficulty with this question.
A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients'
charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and
explains this to the health care provider, but the health care provider tells the nurse that she
will be reported if she does not write the prescriptions. How should the nurse manage this
conflict?
,Select one:
a. Fulfilling the health care provider's request
b. Discussing the situation with the nurse manager
c. Reporting the health care provider to the chief of medicine at the hospital
d. Stating to the health care provider, "I don't really care whether you report me. I am not
writing your prescriptions." - ✔️✔️b. Discussing the situation with the nurse manager
Rationale:
When a conflict arises, it is most appropriate to try resolving the conflict directly. In this
situation, the nurse has tried to explain why she is uncomfortable with the health care
provider's request but has been unable to resolve the conflict. The nurse would then most
appropriately use organizational channels of communication and discuss the issue with the
nurse manager, who would then proceed to resolve the conflict. The nurse manager may
attempt to discuss the situation with the health care provider or seek assistance from the
nursing supervisor. Fulfilling the health care provider's request and writing the prescriptions in
the clients' charts ignores the issue. Reporting the health care provider to the chief of medicine
is inappropriate because the nurse should use the appropriate organizational channels of
communication to resolve the conflict. Stating "I don't care whether you report me. I am not
writing your prescriptions" is an inappropriate statement and will result in further conflict
between the nurse and health care provider.
TEST TAKING STRATEGIES:
Use your knowledge of the subject, conflict management, and the process of elimination. First
eliminate the option that ignores the subject. Next eliminate the option that will result in
further conflict between the nurse and health care provider. To select from the remaining
options, think about the appropriate use of the organizational channels of communication; this
will direct you to the correct option. Review the principles of managing conflict if you had
difficulty with this question.
A nurse is planning task assignments for the day. Which task should the nurse assign to the
nursing assistant?
Select one:
a. Suctioning a client who requires periodic suctioning
, b. Performing colostomy irrigation on a client with an ostomy
c. Assisting a client who needs frequent ambulation with a walker
d. Assessing a client who has undergone an arteriogram and requires close monitoring - ✔️✔️c.
Assisting a client who needs frequent ambulation with a walker
Rationale:
When a nurse assigns tasks of a client's care to another staff member, the nurse is responsible
for appropriately assigning tasks on the basis of the educational level and competency of the
staff member. Noninvasive interventions such as ambulating a client with a walker may be
assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy
irrigation should be assigned to a licensed nurse because these staff members can perform
certain invasive procedures. The client who has undergone an arteriogram should be assigned
to a licensed nurse because these personnel have the knowledge and education to detect
changes in the client's status that require attention.
TEST TAKING STRATEGIES:
Use the process of elimination, focusing on the subject of the question, assignment to a nursing
assistant. Eliminate the comparable or alike options that involve invasive procedures. To select
from the remaining options, think about the education that a nursing assistant receives. The
nursing assistant is trained to ambulate a client with an assistive device but does not have the
knowledge and education to detect changes in a client's status. Review the guidelines for
assignment of tasks if you had difficulty with this question.
A case manager is reviewing progress notes in a client's medical record. Which notation
indicates the need for follow-up?
CLIENT 1: status postmastectomy 18 hours - five mL of bloody drainage was emptied from the
Jackson-Pratt drain
CLIENT 2: heart failure - crackles were heard in the lower lung lobes bilaterally on auscultation
CLIENT 3: status postappendectomy 24 hours - The surgical dressing is clean and dry
CLIENT 4: diabetes mellitus - blood glucose level is 124 mg/dL
|Questions with 100% Correct Answers
TEST TAKING STRATEGIES:
Note the strategic word "first." Think about the classification of each medication to determine
its action. This will help you answer correctly. Also note that atorvastatin and zolpidem are
comparable or alike in that they are administered at bedtime. Next, recalling the action of
levothyroxine will direct you to this option. Review the medications in the options and their
method of administration if you had difficulty with this question.
A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action
reflects the use of evidence-based practice in the care of the client?
a. Keeping the door to the client's room closed
b. Using a surgical mask when entering the client's room
c. Placing the client in a semiprivate room with a cohort client
d. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all
times - ✔️✔️a. Keeping the door to the client's room closed
Rationale:
Evidence-based practice is an approach to client care in which the nurse integrates the client's
preferences, clinical expertise, and the best research evidence to deliver quality care.
Pulmonary tuberculosis is a respiratory infection that is transmitted to others by way of the
airborne route. The door to the client's room must be kept closed to prevent the transmission
of the infection via the airborne route. The remaining options do not reflect evidence-based
practice. An N95 or HEPA respirator (not a surgical mask) must be worn by the nurse on
entering the room. It is not necessary for the client to wear a mask. Airborne precautions
require the use of a private room.
TEST TAKING STRATEGIES:
Read each option carefully, focusing on the subject, evidence-based practice. Recall the
definition of evidence-based practice and recall that tuberculosis is transmitted by way of the
,airborne route. This will direct you to the correct option. Review the concept of evidence-based
practice if you had difficulty with this question
A man who is visiting his wife in a long-term care facility for people with Alzheimer disease
collapses and is transported to a hospital. The client remains unconscious, and testing reveals
that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the
wife's care facility report to the hospital health care provider that the client has no other family
members and that his wife is mentally incompetent. What information regarding do-not-
resuscitate (DNR) orders does the nurse remember?
a. That a DNR order may be written by a client's health care provider
b. That everything possible must be done if the client stops breathing
c. That medications only may be given to the client if the client stops breathing
d. That life support measures will have to be implemented if the client stops breathing - ✔️✔️a.
That a DNR order may be written by a client's health care provider
Rationale:
In a situation in which a client has no family members who can provide permission for
treatment, the health care provider may write a DNR order if he or she is reasonably and
medically certain that resuscitation would be futile. Therefore the other options are inaccurate.
TEST TAKING STRATEGIES:
Focus on the data in the question, and note that the client is terminally ill and has no family
members other than a wife who is mentally incompetent. Eliminate the comparable or alike
options that indicate that resuscitation measures will be instituted. Next eliminate the option
containing the closed-ended word "only." Review the ethical and legal issues related to DNR
orders if you had difficulty with this question.
A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients'
charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and
explains this to the health care provider, but the health care provider tells the nurse that she
will be reported if she does not write the prescriptions. How should the nurse manage this
conflict?
,Select one:
a. Fulfilling the health care provider's request
b. Discussing the situation with the nurse manager
c. Reporting the health care provider to the chief of medicine at the hospital
d. Stating to the health care provider, "I don't really care whether you report me. I am not
writing your prescriptions." - ✔️✔️b. Discussing the situation with the nurse manager
Rationale:
When a conflict arises, it is most appropriate to try resolving the conflict directly. In this
situation, the nurse has tried to explain why she is uncomfortable with the health care
provider's request but has been unable to resolve the conflict. The nurse would then most
appropriately use organizational channels of communication and discuss the issue with the
nurse manager, who would then proceed to resolve the conflict. The nurse manager may
attempt to discuss the situation with the health care provider or seek assistance from the
nursing supervisor. Fulfilling the health care provider's request and writing the prescriptions in
the clients' charts ignores the issue. Reporting the health care provider to the chief of medicine
is inappropriate because the nurse should use the appropriate organizational channels of
communication to resolve the conflict. Stating "I don't care whether you report me. I am not
writing your prescriptions" is an inappropriate statement and will result in further conflict
between the nurse and health care provider.
TEST TAKING STRATEGIES:
Use your knowledge of the subject, conflict management, and the process of elimination. First
eliminate the option that ignores the subject. Next eliminate the option that will result in
further conflict between the nurse and health care provider. To select from the remaining
options, think about the appropriate use of the organizational channels of communication; this
will direct you to the correct option. Review the principles of managing conflict if you had
difficulty with this question.
A nurse is planning task assignments for the day. Which task should the nurse assign to the
nursing assistant?
Select one:
a. Suctioning a client who requires periodic suctioning
, b. Performing colostomy irrigation on a client with an ostomy
c. Assisting a client who needs frequent ambulation with a walker
d. Assessing a client who has undergone an arteriogram and requires close monitoring - ✔️✔️c.
Assisting a client who needs frequent ambulation with a walker
Rationale:
When a nurse assigns tasks of a client's care to another staff member, the nurse is responsible
for appropriately assigning tasks on the basis of the educational level and competency of the
staff member. Noninvasive interventions such as ambulating a client with a walker may be
assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy
irrigation should be assigned to a licensed nurse because these staff members can perform
certain invasive procedures. The client who has undergone an arteriogram should be assigned
to a licensed nurse because these personnel have the knowledge and education to detect
changes in the client's status that require attention.
TEST TAKING STRATEGIES:
Use the process of elimination, focusing on the subject of the question, assignment to a nursing
assistant. Eliminate the comparable or alike options that involve invasive procedures. To select
from the remaining options, think about the education that a nursing assistant receives. The
nursing assistant is trained to ambulate a client with an assistive device but does not have the
knowledge and education to detect changes in a client's status. Review the guidelines for
assignment of tasks if you had difficulty with this question.
A case manager is reviewing progress notes in a client's medical record. Which notation
indicates the need for follow-up?
CLIENT 1: status postmastectomy 18 hours - five mL of bloody drainage was emptied from the
Jackson-Pratt drain
CLIENT 2: heart failure - crackles were heard in the lower lung lobes bilaterally on auscultation
CLIENT 3: status postappendectomy 24 hours - The surgical dressing is clean and dry
CLIENT 4: diabetes mellitus - blood glucose level is 124 mg/dL
