HESI - FUNDAMENTALS PRACTICE QUEST
CORRECT ANSWERS
When cturning can cimmobile cbedridden cclient cwithout cassistance, cwhich caction cby cthe cnurse cbe
A. cSecurely cgrasp cthe cclient's carm cand cleg.
B. cPut cbed crails cup con cthe cside cof cbed copposite cfrom cthe cnurse.
C. cCorrectly cposition cand cuse ca cturn csheet.
D. cLower cthe chead cof cthe cclient's cbed cslowly. c- cCORRECT cANS✔✔B
Rationale: cBecause cthe cnurse ccan conly cstand con cone cside cof cthe cbed, cbed crails cshould cbe cu
censure cthat cthe cclient cdoes cnot cfall cout cof cbed. cOption cA ccan ccause cclient cinjury cto cthe cskin
care cuseful ctechniques cwhile cturning ca cclient cbut chave cless cpriority cin cterms cof csafety cthan cus
The cnurse cidentifies ca cpotential cfor cinfection cin ca cclient cwith cpartial-thickness c(second-degree)
degree) cburns. cWhat cintervention chas cthe chighest cpriority cin cdecreasing cthe cclient's crisk cof cinf
A. cAdministration cof cplasma cexpanders
B. cUse cof ccareful chandwashing ctechnique
C. cApplication cof ca ctopical cantibacterial ccream
D. cLimiting cvisitors cto cthe cclient cwith cburns c- cCORRECT cANS✔✔B
Rationale: cCareful chandwashing ctechnique cis cthe csingle cmost ceffective cintervention cfor cthe cpre
call cclients. cOption cA creverses cthe chypovolemia cthat cinitially caccompanies cburn ctrauma cbut cis
cproliferation cof cinfective corganisms. cOptions cC cand cD care crecommended cby cvarious cburn ccen
creduce cthe cchance cof cinfection. cOption cB cis ca cproven ctechnique cto cprevent cinfection.
The cnurse cis caware cthat cmalnutrition cis ca ccommon cproblem camong cclients cserved cby ca ccomm
chomeless. cWhich claboratory cvalue cis cthe cmost creliable cindicator cof cchronic cprotein cmalnutritio
A. cLow cserum calbumin clevel
B. cLow cserum ctransferrin clevel
C. cHigh chemoglobin clevel
,The cnurse cis cassessing cseveral cclients cprior cto csurgery. cWhich cfactor cin ca cclient's chistory cpos
ccomplications cto coccur cduring csurgery?
A. cTaking cbirth ccontrol cpills cfor cthe cpast c2 cyears
B. cTaking canticoagulants cfor cthe cpast cyear
C. cRecently ccompleting cantibiotic ctherapy
D. cHaving ctaken claxatives cPRN cfor cthe clast c6 cmonths c- cCORRECT cANS✔✔B
Rationale:
Anticoagulants cincrease cthe crisk cfor cbleeding cduring csurgery, cwhich ccan cpose ca cthreat cfor cthe
ccomplications. cThe chealth ccare cprovider cshould cbe cinformed cthat cthe cclient cis ctaking cthese cd
ctake cbirth ccontrol cpills cmay cbe cmore csusceptible cto cthe cdevelopment cof cthrombi, csuch cproble
cpostoperatively. cA cclient cwith coption cC cor cD cis cat cless cof ca csurgical crisk cthan cwith coption cB.
When cassisting ca cclient cfrom cthe cbed cto ca cchair, cwhich cprocedure cis cbest cfor cthe cnurse cto cfo
A. cPlace cthe cchair cparallel cto cthe cbed, cwith cits cback ctoward cthe chead cof cthe cbed cand cassist
cchair.
B. cWith cthe cnurse's cfeet cspread capart cand cknees caligned cwith cthe cclient's cknees, cstand cand c
C. cAssist cthe cclient cto ca cstanding cposition cby cgently clifting cupward, cunderneath cthe caxillae.
D. cStand cbeside cthe cclient, cplace cthe cclient's carms caround cthe cnurse's cneck, cand cgently cmov
cCORRECT cANS✔✔B
Rationale: cOption cB cdescribes cthe ccorrect cpositioning cof cthe cnurse cand caffords cthe cnurse ca cw
cstabilizing cthe cclient's cknees cwhen cassisting cto ca cstanding cposition. cThe cchair cshould cbe cplac
cthe cbed, cwith cthe cback cof cthe cchair ctoward cthe chead cof cthe cbed. cClients cshould cnever cbe clif
ccould cdamage cnerves cand cstrain cthe cnurse's cback. cThe cclient cshould cbe cinstructed cto cuse cth
cshould cnever cplace chis cor cher carms caround cthe cnurse's cneck; cthis cplaces cundue cstress con ct
cand cincreases cthe crisk cfor ca cfall.
Which cstep(s) cshould cthe cnurse ctake cwhen cadministering cear cdrops cto can cadult cclient? c(Selec
A. cPlace cthe cclient cin ca cside-lying cposition.
B. cPull cthe cauricle cupward cand coutward.
C. cHold cthe cdropper c6 ccm cabove cthe cear ccanal.
D. cPlace ca ccotton cball cinto cthe cinner ccanal.
E. cPull cthe cauricle cdown cand cback. c- cCORRECT cANS✔✔A, cB
Rationale: cThe ccorrect canswers c(A cand cB) care cthe cappropriate cadministration cof cear cdrops. cT
ccm c(½ cinch) cabove cthe cear ccanal c(C). cA ccotton cball cshould cbe cplaced cin cthe coutermost ccan
cdown cand cback cfor ca cchild cyounger cthan c3 cyears cof cage, cbut cnot can cadult c(E).
The cnurse cis cinstructing ca cclient cin cthe cproper cuse cof ca cmetered-dose cinhaler. cWhich cinstruct
cthe cclient cto censure cthe coptimal cbenefits cfrom cthe cdrug?
A. c"Fill cyour clungs cwith cair cthrough cyour cmouth cand cthen ccompress cthe cinhaler."
B. c"Compress cthe cinhaler cwhile cslowly cbreathing cin cthrough cyour cmouth."
C. c"Compress cthe cinhaler cwhile cinhaling cquickly cthrough cyour cnose."
D. c"Exhale ccompletely cafter ccompressing cthe cinhaler cand cthen cinhale." c- cCORRECT cANS✔✔B
Rationale: cThe cmedication cshould cbe cinhaled cthrough cthe cmouth csimultaneously cwith ccompres
cfacilitate cthe cdesired cdestination cof cthe caerosol cmedication cdeep cin cthe clungs cfor can coptimal
cA, cC, cand cD cdo cnot callow cfor cdeep clung cpenetration.
A c20-year-old cfemale cclient cwith ca cnoticeable cbody codor chas crefused cto cshower cfor cthe clast c3
cbeen ctold cthat cit cis charmful cto cbathe cduring cmy cperiod." cWhich caction cshould cthe cnurse ctake
A. cAccept cand cdocument cthe cclient's cwish cto crefrain cfrom cbathing.
B. cOffer cto cgive cthe cclient ca cbed cbath, cavoiding cthe cperineal carea.
C. cObtain cwritten cbrochures cabout cmenstruation cto cgive cto cthe cclient.
D. cTeach cthe cimportance cof cpersonal chygiene cduring cmenstruation cwith cthe cclient. c- cCORREC
Rationale: cBecause ca cshower cis cmost cbeneficial cfor cthe cclient cin cterms cof chygiene, cthe cclient
crespecting cany cpersonal cbeliefs csuch cas ccultural cor cspiritual cvalues. cAfter cclient cteaching, cthe
cA cor cB. cBrochures creinforce cthe cteaching.
,The cnurse cplans cto cadminister cdiazepam, c4 cmg cIV cpush, cto ca cclient cwith csevere canxiety. cHow
cnurse cadminister? c(Round cto cthe cnearest ctenth.)
A. c0.2 cmL
B. c0.8 cmL
C. c1.25 cmL
D. c2.0 cmL c- cCORRECT cANS✔✔B
Rationale: c(1 cmL c× c4 cmg)/5 cmg c= c0.8 cmL
The cnurse cprepares cto cinsert ca cnasogastric ctube cin ca cclient cwith chyperemesis cwho cis cawake
cintervention(s) cis(are) ccorrect? c(Select call cthat capply.)
A. cPlace cthe cclient cin ca chigh cFowler cposition.
B. cHelp cthe cclient cassume ca cleft cside-lying cposition.
C. cMeasure cthe ctube cfrom cthe ctip cof cthe cnose cto cthe cumbilicus.
D. cInstruct cthe cclient cto cswallow cafter cthe ctube chas cpassed cthe cpharynx.
E. cAssist cthe cclient cin cextending cthe cneck cback cso cthe ctube cmay center cthe clarynx. c- cCORRE
Rationale:
(A cand cD) care cthe ccorrect csteps cto cfollow cduring cnasogastric cintubation. cOnly cthe cunconsciou
cbe cplaced cin ca cleft cside-lying cposition c(B). cThe ctube cshould cbe cmeasured cfrom cthe ctip cof cthe
cthen cfrom cbehind cthe cear cto cthe cxiphoid cprocess c(C). cThe cneck cshould conly cbe cextended cba
cthe cpharynx cand cthen cthe cclient cshould cbe cinstructed cto cposition cthe cneck cforward c(E).
The cnurse cteaches cthe cuse cof ca cgait cbelt cto ca cmale ccaregiver cwhose cwife chas cright-sided cwe
cwith cambulation. cThe ccaregiver cperforms ca creturn cdemonstration cof cthe cskill. cWhich cobservat
chas clearned chow cto cperform cthis cprocedure ccorrectly?
A. cStanding con chis cwife's cstrong cside, cthe ccaregiver cis cready cto chold cthe cgait cbelt cif cany cevid
cobserved.
B. cStanding con chis cwife's cweak cside, cthe ccaregiver cprovides csecurity cby cholding cthe cgait cbelt
C. cStanding cbehind chis cwife, cthe ccaregiver cprovides cbalance cby cholding cboth csides cof cthe cga
D. cStanding cslightly cin cfront cand cto cthe cright cof chis cwife, cthe ccaregiver cguides cher cforward cby
cbelt. c- cCORRECT cANS✔✔B
Rationale: cHis cwife cis cmost clikely cto clean ctoward cthe cweak cside cand cneeds cextra csupport con
cto cprevent cfalling. cOptions cA, cC, cand cD cprovide cless csecurity cfor cher.
Which cnursing cdiagnosis chas cthe chighest cpriority cwhen cplanning ccare cfor ca cclient cwith can cind
A. cSelf-care cdeficit
B. cFunctional cincontinence
C. cFluid cvolume cdeficit
D. cHigh crisk cfor cinfection c- cCORRECT cANS✔✔D
Rationale: cIndwelling curinary ccatheters care ca cmajor csource cof cinfection. cOptions cA cand cB care
crequire can cindwelling ccatheter. cOption cC cis cnot caffected cby can cindwelling ccatheter.
A cclient chas ca cnursing cdiagnosis cof cAltered csleep cpatterns crelated cto cnocturia. cWhich cclient cin
cnurse cto cprovide?
A. cDecrease cintake cof cfluids cafter cthe cevening cmeal.
B. cDrink ca cglass cof ccranberry cjuice cevery cday.
C. cDrink ca cglass cof cwarm cdecaffeinated cbeverage cat cbedtime.
D. cConsult cthe chealth ccare cprovider cabout ca csleeping cpill. c- cCORRECT cANS✔✔A
Rationale: cNocturia cis curination cduring cthe cnight. cOption cA cis chelpful cto cdecrease cthe cproduct
cthe cneed cto cvoid cat cnight. cOption cB chelps cprevent cbladder cinfections. cOption cC cmay cpromote
ccontribute cto cnocturia. cOption cD cmay cresult cin curinary cincontinence cif cthe cclient cis csedated ca
When cperforming csterile cwound ccare cin cthe cacute ccare csetting, cthe cnurse cobtains ca cbottle cof
cbedside ctable cthat cis clabeled c"opened" cand cdated c48 chours cprior cto cthe ccurrent cdate. cWhich
cnurse cto ctake?
A. cUse cthe cnormal csaline csolution conce cmore cand cthen cdiscard.
, B. cReinflate cthe ccuff ccompletely cand cleave cit cinflated cfor c90 cto c110 cseconds cbefore ctaking cth
C. cDeflate cthe ccuff cto czero cand cwait c30 cto c60 cseconds cbefore creattempting cthe creading.
D. cDocument cthe cexact clevel cvisualized con cthe csphygmomanometer cwhere cthe cfirst cfluctuation
cANS✔✔C
Rationale: cDeflating cthe ccuff cfor c30 cto c60 cseconds callows cblood cflow cto creturn cto cthe cextremi
ccan cbe cobtained con cthat cextremity ca csecond ctime. cOption cA ccould cresult cin ca cfalsely chigh cre
ccirculation, ccauses cpain, cand ccould calter cthe creading. cOption cD cis cnot can caccurate cmethod co
A cclient's cblood cpressure creading cis c156/94 cmm cHg. cWhich caction cshould cthe cnurse ctake cfirs
A. cTell cthe cclient cthat cthe cblood cpressure cis chigh cand cthat cthe creading cneeds cto cbe cverified c
B. cContact cthe chealth ccare cprovider cto creport cthe creading cand cobtain ca cprescription cfor can can
C. cReplace cthe ccuff cwith ca clarger cone cto censure can cample cfit cfor cthe cclient cto cincrease carm c
D. cCompare cthe ccurrent creading cwith cthe cclient's cpreviously cdocumented cblood cpressure cread
Rationale: cComparing cthis creading cwith cprevious creadings cwill cprovide cinformation cabout cwhat
caction cshould cbe ctaken cfirst. cOption cA cmight cunnecessarily calarm cthe cclient. cOption cB cis cpre
cneeded cto cdetermine cif cthe creading cis cabnormal cfor cthis cclient. cOption cC ccould cfalsely cdecre
cthe ccorrect cprocedure cfor cobtaining ca cblood cpressure creading.
A cnurse cstops cat ca cmotor cvehicle ccollision csite cto crender caid cuntil cthe cemergency cpersonnel c
ca cgroin cwound cthat cis cbleeding cprofusely. cLater cthe cclient chas cto chave cthe cleg camputated can
cmalpractice. cWhich cis cthe cmost clikely coutcome cof cthis clawsuit?
A. cThe cPatient's cBill cof cRights cprotects cclients cfrom cmalicious cintents, cso cthe cnurse ccould clos
B. cThe clawsuit cmay cbe csettled cout cof ccourt, cbut cthe cnurse's clicense cis clikely cto cbe crevoked.
C. cThere cwill cbe cno cjudgment cagainst cthe cnurse, cwhose cactions cwere cprotected cunder cthe cG
D. cThe cclient cwill cwin cbecause cthe cfour celements cof cnegligence c(duty, cbreach, ccausation, cand
cCORRECT cANS✔✔C
Rationale: cThe cGood cSamaritan cAct cprotects chealth ccare cprofessionals cwho cpractice cin cgood c
ccare cfrom cmalpractice cclaims, cregardless cof cthe cclient coutcome. cAlthough cthe cPatient's cBill co
cnurse cis cprotected cby cthe cGood cSamaritan cAct. cThe cstate cBoard cof cNursing chas cno creason c
clicense cunless cthere cwas cevidence cthat cactions ctaken cin cthe cemergency cwere cnot cdone cin cg
ccare cwas cnot cprovided. cAll cfour celements cof cmalpractice cwere cnot cshown.
When cthe chealth ccare cprovider cdiagnoses cmetastatic ccancer cand crecommends ca cgastrostomy
cstable ccondition, cthe cson ctells cthe cnurse cthat chis cmother cmust cnot cbe ctold cthe creason cfor cth
chandle" cthe ccancer cdiagnosis. cWhich clegal cprinciple cis cthe ccourt cmost clikely cto cuphold cregard
cinformed cconsent?
A. cThe cfamily ccan cprovide cthe cconsent crequired cin cthis csituation cbecause cthe colder cadult cis ci
cdecisions.
B. cBecause cthe cclient cis cmentally cincompetent, cthe cson chas cthe cright cto cwaive cinformed ccons
C. cThe ccourt cwill callow cthe chealth ccare cprovider cto cmake cthe cdecision cto cwithhold cinformed cc
cprivilege.
D. cIf cinformed cconsent cis cwithheld cfrom ca cclient, chealth ccare cproviders ccould cbe cfound cguilty
cANS✔✔D
Rationale: cHealth ccare cproviders cmay cbe cfound cguilty cof cnegligence, cspecifically cassault cand c
ctreatment cwithout cthe cclient's cconsent. cThe cclient's ccondition cis cstable, cso coption cA cis cnot ca c
cdoes cnot cautomatically cauthorize cthe cson cto cmake call cdecisions cfor chis cmother, cand cthere cis
cmentally cincompetent. cAlthough coption cC cmay chave cbeen cupheld cin cthe cpast, cwhen cpaternali
ccommon, ctoday's ccourts care cunlikely cto caccept cit.
The cnurse cis cobtaining ca clie-sit-stand cblood cpressure creading con ca cclient. cWhich caction cis cmo
cimplement?
A. cStay cwith cthe cclient cwhile cthe cclient cis cstanding.
B. cRecord cthe cfindings con cthe cgraphic csheet cin cthe cchart.
C. cKeep cthe cblood cpressure ccuff con cthe csame carm.
D. cRecord cchanges cin cthe cclient's cpulse crate. c- cCORRECT cANS✔✔A
CORRECT ANSWERS
When cturning can cimmobile cbedridden cclient cwithout cassistance, cwhich caction cby cthe cnurse cbe
A. cSecurely cgrasp cthe cclient's carm cand cleg.
B. cPut cbed crails cup con cthe cside cof cbed copposite cfrom cthe cnurse.
C. cCorrectly cposition cand cuse ca cturn csheet.
D. cLower cthe chead cof cthe cclient's cbed cslowly. c- cCORRECT cANS✔✔B
Rationale: cBecause cthe cnurse ccan conly cstand con cone cside cof cthe cbed, cbed crails cshould cbe cu
censure cthat cthe cclient cdoes cnot cfall cout cof cbed. cOption cA ccan ccause cclient cinjury cto cthe cskin
care cuseful ctechniques cwhile cturning ca cclient cbut chave cless cpriority cin cterms cof csafety cthan cus
The cnurse cidentifies ca cpotential cfor cinfection cin ca cclient cwith cpartial-thickness c(second-degree)
degree) cburns. cWhat cintervention chas cthe chighest cpriority cin cdecreasing cthe cclient's crisk cof cinf
A. cAdministration cof cplasma cexpanders
B. cUse cof ccareful chandwashing ctechnique
C. cApplication cof ca ctopical cantibacterial ccream
D. cLimiting cvisitors cto cthe cclient cwith cburns c- cCORRECT cANS✔✔B
Rationale: cCareful chandwashing ctechnique cis cthe csingle cmost ceffective cintervention cfor cthe cpre
call cclients. cOption cA creverses cthe chypovolemia cthat cinitially caccompanies cburn ctrauma cbut cis
cproliferation cof cinfective corganisms. cOptions cC cand cD care crecommended cby cvarious cburn ccen
creduce cthe cchance cof cinfection. cOption cB cis ca cproven ctechnique cto cprevent cinfection.
The cnurse cis caware cthat cmalnutrition cis ca ccommon cproblem camong cclients cserved cby ca ccomm
chomeless. cWhich claboratory cvalue cis cthe cmost creliable cindicator cof cchronic cprotein cmalnutritio
A. cLow cserum calbumin clevel
B. cLow cserum ctransferrin clevel
C. cHigh chemoglobin clevel
,The cnurse cis cassessing cseveral cclients cprior cto csurgery. cWhich cfactor cin ca cclient's chistory cpos
ccomplications cto coccur cduring csurgery?
A. cTaking cbirth ccontrol cpills cfor cthe cpast c2 cyears
B. cTaking canticoagulants cfor cthe cpast cyear
C. cRecently ccompleting cantibiotic ctherapy
D. cHaving ctaken claxatives cPRN cfor cthe clast c6 cmonths c- cCORRECT cANS✔✔B
Rationale:
Anticoagulants cincrease cthe crisk cfor cbleeding cduring csurgery, cwhich ccan cpose ca cthreat cfor cthe
ccomplications. cThe chealth ccare cprovider cshould cbe cinformed cthat cthe cclient cis ctaking cthese cd
ctake cbirth ccontrol cpills cmay cbe cmore csusceptible cto cthe cdevelopment cof cthrombi, csuch cproble
cpostoperatively. cA cclient cwith coption cC cor cD cis cat cless cof ca csurgical crisk cthan cwith coption cB.
When cassisting ca cclient cfrom cthe cbed cto ca cchair, cwhich cprocedure cis cbest cfor cthe cnurse cto cfo
A. cPlace cthe cchair cparallel cto cthe cbed, cwith cits cback ctoward cthe chead cof cthe cbed cand cassist
cchair.
B. cWith cthe cnurse's cfeet cspread capart cand cknees caligned cwith cthe cclient's cknees, cstand cand c
C. cAssist cthe cclient cto ca cstanding cposition cby cgently clifting cupward, cunderneath cthe caxillae.
D. cStand cbeside cthe cclient, cplace cthe cclient's carms caround cthe cnurse's cneck, cand cgently cmov
cCORRECT cANS✔✔B
Rationale: cOption cB cdescribes cthe ccorrect cpositioning cof cthe cnurse cand caffords cthe cnurse ca cw
cstabilizing cthe cclient's cknees cwhen cassisting cto ca cstanding cposition. cThe cchair cshould cbe cplac
cthe cbed, cwith cthe cback cof cthe cchair ctoward cthe chead cof cthe cbed. cClients cshould cnever cbe clif
ccould cdamage cnerves cand cstrain cthe cnurse's cback. cThe cclient cshould cbe cinstructed cto cuse cth
cshould cnever cplace chis cor cher carms caround cthe cnurse's cneck; cthis cplaces cundue cstress con ct
cand cincreases cthe crisk cfor ca cfall.
Which cstep(s) cshould cthe cnurse ctake cwhen cadministering cear cdrops cto can cadult cclient? c(Selec
A. cPlace cthe cclient cin ca cside-lying cposition.
B. cPull cthe cauricle cupward cand coutward.
C. cHold cthe cdropper c6 ccm cabove cthe cear ccanal.
D. cPlace ca ccotton cball cinto cthe cinner ccanal.
E. cPull cthe cauricle cdown cand cback. c- cCORRECT cANS✔✔A, cB
Rationale: cThe ccorrect canswers c(A cand cB) care cthe cappropriate cadministration cof cear cdrops. cT
ccm c(½ cinch) cabove cthe cear ccanal c(C). cA ccotton cball cshould cbe cplaced cin cthe coutermost ccan
cdown cand cback cfor ca cchild cyounger cthan c3 cyears cof cage, cbut cnot can cadult c(E).
The cnurse cis cinstructing ca cclient cin cthe cproper cuse cof ca cmetered-dose cinhaler. cWhich cinstruct
cthe cclient cto censure cthe coptimal cbenefits cfrom cthe cdrug?
A. c"Fill cyour clungs cwith cair cthrough cyour cmouth cand cthen ccompress cthe cinhaler."
B. c"Compress cthe cinhaler cwhile cslowly cbreathing cin cthrough cyour cmouth."
C. c"Compress cthe cinhaler cwhile cinhaling cquickly cthrough cyour cnose."
D. c"Exhale ccompletely cafter ccompressing cthe cinhaler cand cthen cinhale." c- cCORRECT cANS✔✔B
Rationale: cThe cmedication cshould cbe cinhaled cthrough cthe cmouth csimultaneously cwith ccompres
cfacilitate cthe cdesired cdestination cof cthe caerosol cmedication cdeep cin cthe clungs cfor can coptimal
cA, cC, cand cD cdo cnot callow cfor cdeep clung cpenetration.
A c20-year-old cfemale cclient cwith ca cnoticeable cbody codor chas crefused cto cshower cfor cthe clast c3
cbeen ctold cthat cit cis charmful cto cbathe cduring cmy cperiod." cWhich caction cshould cthe cnurse ctake
A. cAccept cand cdocument cthe cclient's cwish cto crefrain cfrom cbathing.
B. cOffer cto cgive cthe cclient ca cbed cbath, cavoiding cthe cperineal carea.
C. cObtain cwritten cbrochures cabout cmenstruation cto cgive cto cthe cclient.
D. cTeach cthe cimportance cof cpersonal chygiene cduring cmenstruation cwith cthe cclient. c- cCORREC
Rationale: cBecause ca cshower cis cmost cbeneficial cfor cthe cclient cin cterms cof chygiene, cthe cclient
crespecting cany cpersonal cbeliefs csuch cas ccultural cor cspiritual cvalues. cAfter cclient cteaching, cthe
cA cor cB. cBrochures creinforce cthe cteaching.
,The cnurse cplans cto cadminister cdiazepam, c4 cmg cIV cpush, cto ca cclient cwith csevere canxiety. cHow
cnurse cadminister? c(Round cto cthe cnearest ctenth.)
A. c0.2 cmL
B. c0.8 cmL
C. c1.25 cmL
D. c2.0 cmL c- cCORRECT cANS✔✔B
Rationale: c(1 cmL c× c4 cmg)/5 cmg c= c0.8 cmL
The cnurse cprepares cto cinsert ca cnasogastric ctube cin ca cclient cwith chyperemesis cwho cis cawake
cintervention(s) cis(are) ccorrect? c(Select call cthat capply.)
A. cPlace cthe cclient cin ca chigh cFowler cposition.
B. cHelp cthe cclient cassume ca cleft cside-lying cposition.
C. cMeasure cthe ctube cfrom cthe ctip cof cthe cnose cto cthe cumbilicus.
D. cInstruct cthe cclient cto cswallow cafter cthe ctube chas cpassed cthe cpharynx.
E. cAssist cthe cclient cin cextending cthe cneck cback cso cthe ctube cmay center cthe clarynx. c- cCORRE
Rationale:
(A cand cD) care cthe ccorrect csteps cto cfollow cduring cnasogastric cintubation. cOnly cthe cunconsciou
cbe cplaced cin ca cleft cside-lying cposition c(B). cThe ctube cshould cbe cmeasured cfrom cthe ctip cof cthe
cthen cfrom cbehind cthe cear cto cthe cxiphoid cprocess c(C). cThe cneck cshould conly cbe cextended cba
cthe cpharynx cand cthen cthe cclient cshould cbe cinstructed cto cposition cthe cneck cforward c(E).
The cnurse cteaches cthe cuse cof ca cgait cbelt cto ca cmale ccaregiver cwhose cwife chas cright-sided cwe
cwith cambulation. cThe ccaregiver cperforms ca creturn cdemonstration cof cthe cskill. cWhich cobservat
chas clearned chow cto cperform cthis cprocedure ccorrectly?
A. cStanding con chis cwife's cstrong cside, cthe ccaregiver cis cready cto chold cthe cgait cbelt cif cany cevid
cobserved.
B. cStanding con chis cwife's cweak cside, cthe ccaregiver cprovides csecurity cby cholding cthe cgait cbelt
C. cStanding cbehind chis cwife, cthe ccaregiver cprovides cbalance cby cholding cboth csides cof cthe cga
D. cStanding cslightly cin cfront cand cto cthe cright cof chis cwife, cthe ccaregiver cguides cher cforward cby
cbelt. c- cCORRECT cANS✔✔B
Rationale: cHis cwife cis cmost clikely cto clean ctoward cthe cweak cside cand cneeds cextra csupport con
cto cprevent cfalling. cOptions cA, cC, cand cD cprovide cless csecurity cfor cher.
Which cnursing cdiagnosis chas cthe chighest cpriority cwhen cplanning ccare cfor ca cclient cwith can cind
A. cSelf-care cdeficit
B. cFunctional cincontinence
C. cFluid cvolume cdeficit
D. cHigh crisk cfor cinfection c- cCORRECT cANS✔✔D
Rationale: cIndwelling curinary ccatheters care ca cmajor csource cof cinfection. cOptions cA cand cB care
crequire can cindwelling ccatheter. cOption cC cis cnot caffected cby can cindwelling ccatheter.
A cclient chas ca cnursing cdiagnosis cof cAltered csleep cpatterns crelated cto cnocturia. cWhich cclient cin
cnurse cto cprovide?
A. cDecrease cintake cof cfluids cafter cthe cevening cmeal.
B. cDrink ca cglass cof ccranberry cjuice cevery cday.
C. cDrink ca cglass cof cwarm cdecaffeinated cbeverage cat cbedtime.
D. cConsult cthe chealth ccare cprovider cabout ca csleeping cpill. c- cCORRECT cANS✔✔A
Rationale: cNocturia cis curination cduring cthe cnight. cOption cA cis chelpful cto cdecrease cthe cproduct
cthe cneed cto cvoid cat cnight. cOption cB chelps cprevent cbladder cinfections. cOption cC cmay cpromote
ccontribute cto cnocturia. cOption cD cmay cresult cin curinary cincontinence cif cthe cclient cis csedated ca
When cperforming csterile cwound ccare cin cthe cacute ccare csetting, cthe cnurse cobtains ca cbottle cof
cbedside ctable cthat cis clabeled c"opened" cand cdated c48 chours cprior cto cthe ccurrent cdate. cWhich
cnurse cto ctake?
A. cUse cthe cnormal csaline csolution conce cmore cand cthen cdiscard.
, B. cReinflate cthe ccuff ccompletely cand cleave cit cinflated cfor c90 cto c110 cseconds cbefore ctaking cth
C. cDeflate cthe ccuff cto czero cand cwait c30 cto c60 cseconds cbefore creattempting cthe creading.
D. cDocument cthe cexact clevel cvisualized con cthe csphygmomanometer cwhere cthe cfirst cfluctuation
cANS✔✔C
Rationale: cDeflating cthe ccuff cfor c30 cto c60 cseconds callows cblood cflow cto creturn cto cthe cextremi
ccan cbe cobtained con cthat cextremity ca csecond ctime. cOption cA ccould cresult cin ca cfalsely chigh cre
ccirculation, ccauses cpain, cand ccould calter cthe creading. cOption cD cis cnot can caccurate cmethod co
A cclient's cblood cpressure creading cis c156/94 cmm cHg. cWhich caction cshould cthe cnurse ctake cfirs
A. cTell cthe cclient cthat cthe cblood cpressure cis chigh cand cthat cthe creading cneeds cto cbe cverified c
B. cContact cthe chealth ccare cprovider cto creport cthe creading cand cobtain ca cprescription cfor can can
C. cReplace cthe ccuff cwith ca clarger cone cto censure can cample cfit cfor cthe cclient cto cincrease carm c
D. cCompare cthe ccurrent creading cwith cthe cclient's cpreviously cdocumented cblood cpressure cread
Rationale: cComparing cthis creading cwith cprevious creadings cwill cprovide cinformation cabout cwhat
caction cshould cbe ctaken cfirst. cOption cA cmight cunnecessarily calarm cthe cclient. cOption cB cis cpre
cneeded cto cdetermine cif cthe creading cis cabnormal cfor cthis cclient. cOption cC ccould cfalsely cdecre
cthe ccorrect cprocedure cfor cobtaining ca cblood cpressure creading.
A cnurse cstops cat ca cmotor cvehicle ccollision csite cto crender caid cuntil cthe cemergency cpersonnel c
ca cgroin cwound cthat cis cbleeding cprofusely. cLater cthe cclient chas cto chave cthe cleg camputated can
cmalpractice. cWhich cis cthe cmost clikely coutcome cof cthis clawsuit?
A. cThe cPatient's cBill cof cRights cprotects cclients cfrom cmalicious cintents, cso cthe cnurse ccould clos
B. cThe clawsuit cmay cbe csettled cout cof ccourt, cbut cthe cnurse's clicense cis clikely cto cbe crevoked.
C. cThere cwill cbe cno cjudgment cagainst cthe cnurse, cwhose cactions cwere cprotected cunder cthe cG
D. cThe cclient cwill cwin cbecause cthe cfour celements cof cnegligence c(duty, cbreach, ccausation, cand
cCORRECT cANS✔✔C
Rationale: cThe cGood cSamaritan cAct cprotects chealth ccare cprofessionals cwho cpractice cin cgood c
ccare cfrom cmalpractice cclaims, cregardless cof cthe cclient coutcome. cAlthough cthe cPatient's cBill co
cnurse cis cprotected cby cthe cGood cSamaritan cAct. cThe cstate cBoard cof cNursing chas cno creason c
clicense cunless cthere cwas cevidence cthat cactions ctaken cin cthe cemergency cwere cnot cdone cin cg
ccare cwas cnot cprovided. cAll cfour celements cof cmalpractice cwere cnot cshown.
When cthe chealth ccare cprovider cdiagnoses cmetastatic ccancer cand crecommends ca cgastrostomy
cstable ccondition, cthe cson ctells cthe cnurse cthat chis cmother cmust cnot cbe ctold cthe creason cfor cth
chandle" cthe ccancer cdiagnosis. cWhich clegal cprinciple cis cthe ccourt cmost clikely cto cuphold cregard
cinformed cconsent?
A. cThe cfamily ccan cprovide cthe cconsent crequired cin cthis csituation cbecause cthe colder cadult cis ci
cdecisions.
B. cBecause cthe cclient cis cmentally cincompetent, cthe cson chas cthe cright cto cwaive cinformed ccons
C. cThe ccourt cwill callow cthe chealth ccare cprovider cto cmake cthe cdecision cto cwithhold cinformed cc
cprivilege.
D. cIf cinformed cconsent cis cwithheld cfrom ca cclient, chealth ccare cproviders ccould cbe cfound cguilty
cANS✔✔D
Rationale: cHealth ccare cproviders cmay cbe cfound cguilty cof cnegligence, cspecifically cassault cand c
ctreatment cwithout cthe cclient's cconsent. cThe cclient's ccondition cis cstable, cso coption cA cis cnot ca c
cdoes cnot cautomatically cauthorize cthe cson cto cmake call cdecisions cfor chis cmother, cand cthere cis
cmentally cincompetent. cAlthough coption cC cmay chave cbeen cupheld cin cthe cpast, cwhen cpaternali
ccommon, ctoday's ccourts care cunlikely cto caccept cit.
The cnurse cis cobtaining ca clie-sit-stand cblood cpressure creading con ca cclient. cWhich caction cis cmo
cimplement?
A. cStay cwith cthe cclient cwhile cthe cclient cis cstanding.
B. cRecord cthe cfindings con cthe cgraphic csheet cin cthe cchart.
C. cKeep cthe cblood cpressure ccuff con cthe csame carm.
D. cRecord cchanges cin cthe cclient's cpulse crate. c- cCORRECT cANS✔✔A
