HESI BSN 225 FUNDAMENTALS IN NURSING REVIEW QUESTIONS AND ANSWERS EXAM 2026

HESI BSN 225 FUNDAMENTALS IN NURSING REVIEW QUESTIONS AND ANSWERS EXAM 2026 The nurse is teaching a client how to self-administer low molecular weight heparin subcutaneously. Which instruction should the nurse include? A. Massage the site it increase absorption B. Rotate the injections between the abdomen and gluteal areas C. Expel the air in the prefilled syringe prior to injection D. Inject in the abdominal area at least 2 inches from the umbilicus D. Inject in the abdominal area at least 2 inches from the umbilicus Injecting in the abdominal area at least 2 inches from the umbilicus is the correct technique for subcutaneous heparin injections, as it reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication Which assessment is most important for the nurse to perform prior to the application of a heating pad A. Limitations to range of motion B. Muscle Strength and Tone C. Degree of Neurosensory D. Presence of rebound phenomenon C. Degree of Neurosensory Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. A heating pad can cause burns or tissue damage if the patient has impaired sensation and cannot feel the heat or pain. The nurse should check the patient's ability to perceive temperature, pressure, and pain before applying a heating pad. BSN 225 BSN 225 The client is a 56-year old woman who had an anteroposterior spinal fusion 2 days ago. She tolerated the procedure well and has been progressively increasing her walking distance. Nurses Notes 1200 - Heart rate: 98 bpm - Pain rating: 5/10 - Morphine 2.5 mg given - The client did ambulation exercises with physical therapy 1300 - Heart rate: 78 bpm - Pain rating: 3/10 - Ibuprofen 800 mg given - The client is resting in bed 1400 Orders - Heart rate 118 bpm Based on the trending heart rate and pain score, what should the nurse do? Select all that apply. A. Lead the client in guided imagery B. Give a dose of 2.5 mg of Morphine C. Assist the client to walk around the room D. Assess for sources of pain other than the surgical site This is a correct choice because guided imagery is a non-pharmacological intervention BSN 225 BSN 225 that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain. The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement? A. Switch to a non-rebreather mask. B. Remove the nasal cannula. C. Increase the oxygen to 3 L/minute. D. Verify the placement of the pulse oximeter. E. Consult with the surgeon about the pain level C. Increase the oxygen to 3 L/minute. Increasing the oxygen to 3 L/minute is the best action for this client. The client has a mild hypoxemia (normal oxygen saturation is 95% or higher) and may benefit from a slight increase in oxygen delivery. A nasal cannula can deliver oxygen at a low flow rate (1 to 6 L/minute) and is suitable for clients who are stable and need mild to moderate oxygen therapy. After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next? A. Notify the healthcare provider. B. Document the event on the chart. C. Complete an incident report. D. Inform the nurse on the next shift A. Notify the healthcare provider. Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible. BSN 225 BSN 225 A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take? A. Irrigate the nasogastric tube with water. B. Review the advance directive document. C. Elevate the head of bed 45 degrees. D. Perform oropharyngeal suctioni C Elevate the head of bed 45 degrees. Elevate the head of bed 45 degrees is the correct action because it helps clear the airway and reduce vomiting. A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage? A Regular exercise. B Stress reduction. C Smoking cessation. D Low-fat diet. C Smoking cessation. Smoking cessation is the most important lifestyle modification because smoking is a major risk factor for cardiac disease. Smoking damages the blood vessels, increases blood pressure, reduces oxygen supply, and promotes clot formation. The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first? A Blood pressure. B Temperature. C Respiratory rate. D Pulse rate. C Respiratory rate. Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity. A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)? BSN 225 BSN 225 A. Have the client hold a pillow over the abdomen to cough and deep breathe. B. Encourage the client to eat all of the meals that are sent. C. Offer fruit juice at least twice during both the day and evening shifts. D. Lower the bed prior to helping the client to move up in bed. D Lower the bed prior to helping the client to move up in bed. Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning. The client is a 44-year-old with cerebral palsy who is non-verbal and has a severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection. Nurses Notes 1000 - Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void. Review H and P and nurse's notes. Identify from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. Potential Conditions Overflow urinary incontinence This is the correct choice because overflow urinary incontinence is the involuntary loss of urine due to a distended bladder that cannot empty completely. The client has cerebral palsy, which can affect the bladder muscles and nerves, causing them to lose coordination and contractility. The client is also non-verbal and has severe intellectual disability, which can impair his ability to sense or communicate the need to void. The BSN 225 BSN 225 client's clothes and sheets are wet, indicating that he has leaked urine. The client voided approximately 75 mL of urine, which is a small amount for an adult male. These signs suggest that the client has overflow urinary incontinence. Actions to Take Provide skin care This is a correct choice because the nurse should provide skin care to the client who has overflow urinary incontinence. The nurse should cleanse the perineal area with mild soap and water, pat dry, and apply a barrier cream or ointment to protect the skin from moisture and irritation. The nurse should also change the client's clothes and sheets as needed to keep him dry and comfortable. Place an incontinence containment product under the client This is a correct choice because the nurse should place an incontinence containment product under the client who has overflow urinary incontinence. An incontinence containment product is a device or material that absorbs or collects urine, such as a diaper, pad, or catheter. The nurse should choose an appropriate product based on the client's preferences, needs, and abilities. The nurse should also monitor the product for leakage, odor, or infection, and change it regularly. Parameters to Monitor Intake and output This is a correct choice because the nurse should monitor the intake and output of the client who has overflow urina A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide? A "I'm sorry, but your child's medical information is none of your business." B "I can give you those results as soon as I get them back from the lab." C "The healthcare provider will share this information with you." D "I can only give medical information to your child because they are legally an adult." D "I can only give medical information to your child because they are legally an adult." "I can only give medical information to your child because they are legally an adult." is a BSN 225 BSN 225 good response because it explains the legal status of an emancipated minor and respects their autonomy. The nurse should inform the parents that their child has the right to make their own decisions regarding their health care. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take? A Remind the UAP to dry between the client's toes completely. B Advise the UAP that this procedure is damaging to the skin. C Add skin cream to the basin of water while the foot is soaking. D Remove the basin of water from the client's bed immediately. D Remove the basin of water from the client's bed immediately. Remove the basin of water from the client's bed immediately is the best action because it prevents potential hazards such as soaking, infection, or electric shock. The nurse should ensure that the bed is dry and clean before continuing with the bath. While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next? A Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading. B Continue the blood pressure assessment until the last Korotkoff sound is heard. C Reposition the stethoscope in the antecubital fossa over the palpable brachial pulse point. D Inflate the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound. A Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading. This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure. After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next? BSN 225 BSN 225 A Reassess the client and the level of pain. B Tell the client the medication needs more time to work. C Ask the UAP to offer a backrub to the client. D Encourage the client to focus on taking deep breaths. A Reassess the client and the level of pain. Reassess the client and the level of pain is the correct intervention because it helps the nurse evaluate the effectiveness of the medication and plan further actions. The nurse should use a valid and reliable pain scale and check for any signs of adverse effects or complications. The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement? A Complete an adverse occurrence/incident report. B Ensure that the restraints are not too tight. C Demonstrate proper securing of the restraints. D Initiate the facility's restraint flow sheet. C Demonstrate proper securing of the restraints. Demonstrate proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails. The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first? A Request a family member to remain with the client. B Ask for the support of one of the client's friends. C Use drawings that are universal for all cultures. D Obtain a staff member who is a bilingual interpreter. D Obtain a staff member who is a bilingual interpreter. Obtain a staff member who is a bilingual interpreter is the best intervention because it facilitates the communication and understanding between the nurse and the client. The interpreter should be trained and certified in medical terminology and cultural sensitivity. A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement? BSN 225 BSN 225 A Instill 50 mL of normal saline solution into the tube and clamp the tube for one hour. B Turn the suction off while allowing the client to rinse his mouth with cool water. C Provide oral sponge toothettes so the client can cleanse and moisten his mouth. D Teach the client that the oral mucosa must remain dry to prevent aspiration. C Provide oral sponge toothettes so the client can cleanse and moisten his mouth. Reason: This is correct because oral sponge toothettes are soft and gentle on the oral mucosa and can help moisten and cleanse the mouth without causing irritation or aspiration. The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone? A Lift and lock the side rails in place. B Apply the client's positive airway pressure device. C Elevate the head of the bed to a 45-degree angle. D Remove dentures or other oral appliances. B Apply the client's positive airway pressure device. Reason: This is correct because applying the client's positive airway pressure device can help maintain airway patency and prevent hypoxia and hypercapnia, which are common complications of OSA and opioid use. Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment? A Abdominal girth. B Bowel sounds. C Vital signs. D Breath sounds. C Vital signs. Reason: This is correct because vital signs can indicate the client's baseline condition and any changes during or after the procedure. Digital removal of a fecal impaction can stimulate the vagus nerve and cause bradycardia, hypotension, or cardiac arrest. A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention? BSN 225 BSN 225 A Palpate the suprapubic region for distention. B Scan the client's bladder after voiding. C Review the chart for number of voids over last 24 hours. D Evaluate the client for urinary incontinence. B Scan the client's bladder after voiding. Reason: This is correct because scanning the client's bladder after voiding can measure the post-void residual urine volume, which indicates the amount of urine left in the bladder after urination. A high post-void residual urine volume can indicate urinary retention. The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority? A Fluid volume deficit. B Bowel incontinence. C Caregiver role strain. D Impaired bed mobility. A Fluid volume deficit. Reason: This is correct because fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement? A Decrease the flow rate to 1 L/minute. B Place padding around the cannula tubing. C Apply lubricant to the cannula tubing. D Discontinue the use of the nasal cannula. B Place padding around the cannula tubing. Reason: This is correct because placing padding around the cannula tubing can prevent pressure ulcers and skin breakdown caused by friction and irritation from the tubing. After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.) BSN 225 BSN 225 A. Provide comfort measures such as topical warm application and tactile massage. B. Assist the client to ambulate as much as possible during waking hours. C. Determine client's subjective measure of pain using a numerical pain scale. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Implement a 24-hour schedule of routine administration of prescribed analgesic. A. Provide comfort measures such as topical warm application and tactile massage. This is correct because providing comfort measures such as topical warm application and tactile massage can help reduce pain perception and promote relaxation by stimulating non-painful sensory receptors. C. Determine client's subjective measure of pain using a numerical pain scale. Choice C Reason: This is correct because determining client's subjective measure of pain using a numerical pain scale can help assess pain severity and effectiveness of pain management interventions. Pain is a subjective experience that varies among individuals. D. Implement a 24-hour schedule of routine administration of prescribed analgesic. Choice E Reason: This is correct because implementing a 24-hour schedule of routine administration of prescribed analgesic can help maintain a steady level of analgesia and prevent breakthrough pain. Chronic pain requires continuous treatment rather than on demand administration. The nurse is teaching the client to self-administer a dose of low-molecular-weight heparin (LMWH) SUBQ. Which instruction should the nurse include? A Massage the injection site to increase absorption. B Expel the air in the prefilled syringe prior to injection. C Rotate injection sites between the abdomen and gluteal areas. D Inject the abdominal area at least 2 in (5.1 cm) from the umbilicus. D. Inject the abdominal area at least 2 in (5.1 cm) from the umbilicus. The nurse is assessing a client who reports a 3-day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: BSN 225 BSN 225 Urine Specific Gravity [1.005 to 1.03] A 1.025. B 1.005. C 1.015. D 1.035. D 1.035. A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document? A Contraction of the left pupil when light shines in the right eye. B Capillary refill of 2 seconds in the lower right foot. C Basilar lung sounds that are diminishes in the left lung. D Active bowel sounds in the lower right quadrant. C Basilar lung sounds that are diminishes in the left lung. The nurse is caring for a male client with diminishes circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet? A On dorsal surfaces. B Over the heels. C Around the ankles. D Between the toes. D Between the toes. The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take? A. Select upper arm as the injection site. B. Massage the site gently after injection. C. Ensure bevel of the needle is pointing up. D. Hold the syringe perpendicular to the skin. D. Hold the syringe perpendicular to the skin. When providing health teaching to older adult clients, which action is most important for the nurse to implement? A. Provide a very well lit meeting space. B. Use everyday language when explaining issues. C. Underline key words on the written information. D. Speak loudly and face the client. B. Use everyday language when explaining issues. The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the comprises a tort? A Administering the medication behind a closed curtain. B Administering a client that the medication being administered is a vitamin. BSN 225 BSN 225 C Placing a client in restraints without having a healthcare provider's order. D Enlisting security personnel to assist with restraining the client. C Placing a client in restraints without having a healthcare provider's order. Which client assessment should the nurse perform during nasopharyngeal suctioning? A. Determine the elasticity of the client's skin turgor. B. Auscultate the bowel sounds in all four quadrants. C. Observe the client's skin and mucous membranes. D. Palpate the client's pedal pulse volume bilaterally. C. Observe the client's skin and mucous membranes. The nurse assesses an older adult woman’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that her posture is upright, and her gait is smooth and steady. Which action should the nurse take next? A. Teach the client to shorten the stride to prevent falls. B. Record the client’s ability to perform ADLs safely. C. Determine the client’s activity tolerance. D. Initiate a fall risk protocol for the client. B. Record the client's ability to perform ADLs safely. A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone? A Elevate the head of the bed to a 45 degree angle. B Apply the client’s positive airway pressure device. C Remove dentures or other oral appliance. D Lift and lock the side rails in place. B Apply the client's positive airway pressure device. A client is admitted with reports of the shortness of breath, dyspnea on exertion, and chest pressure. The healthcare provider prescribes a medication that is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. Which action should the nurse take? A. Consult pharmacist for dose clarification. B. Administer the medication as prescribed. C. Verify the prescribed dosage with healthcare provider. D. Give the dosage recommended in the drug handbook. C. Verify the prescribed dosage with healthcare provider. The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use? A Begin with questions that are less sensitive in nature. B Get the most difficult questions over with first. C Ask questions in a vague, non-specific format. D Share personal values to put the client at ease. BSN 225 BSN 225 A. Begin with questions that are less sensitive in nature. When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L). Which intervention is most important for the nurse to implement? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] A Compare muscle strength bilaterally. B Observe color and amount of urine. C Determine apical pulse rate and rhythm. D Assess strength of deep tendon reflexes. C Determine apical pulse rate and rhythm. Following surgery, a client expresses concern to the nurse about being able to use the bedpan. After noting that the client's prescribed postoperative activity includes getting up to a chair three times a day, how should the nurse intervene? A Offer to position the bedpan on the chair before the client transfers to the chair. B Explain to the client that the head of the bed can be elevated when using the bedpan. C Reassure the client that someone will help with positioning on the bedpan. D Encourage the client to use a bedside commode rather than the bedpan. D Encourage the client to use a bedside commode rather than the bedpan. When identifying the goals to be included in a client's plan of care, the nurse should take which action? A Ensure that all treatments prescribed by the healthcare provider have been initiated. B Review the priority nursing problems included in the plan of care. C Compare the client's manifestations with the defining criteria of related problems. D List the nursing actions that need to be implemented most immediately. C. Compare the client's manifestations with the defining criteria of related problems. The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching? A Positions the head with the chin tilted slightly downward. B Allows 30 minutes of rest before feeding. C Raises the head of the bed to 60 degrees. D Places food on the unaffected side of the mouth. C Raises the head of the bed to 60 degrees. The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the need to additional training? A Suctions secretions from the posterior pharynx. B Places the client in a supine position. C Tests for a gag reflex before performing oral care. D Uses an open airway to keep the teeth apart. BSN 225 BSN 225 B Places the client in a supine position. The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next? A Obtain a new catheter. B Clean the catheter with providone-iodine. C Reposition the legs before reinsertion. D Increase the lighting in the room. A Obtain a new catheter. When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain? A When the client voided following catheter removal. B Intake and output reports for the previous shift. C Time of the last dose of IV antibiotic administration. D Color of the urine during the catheter removal. A When the client voided following catheter removal. What might explain the client’s blood pressure on the day of the procedure? Select all that apply. A The client’s legs were crossed B The blood pressure cuff is too large C Hyponatremia D Anxiety E The arm was positioned above the heart F The blood pressure cuff is too smell G Hypovolemia B. The blood pressure cuff is too large D. Anxiety E. The arm was positioned above the heart G. Hypovolemia A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement? A Encourage the client to exercise every day to eliminate bedtime wakefulness. B Advise the client that lifestyle changes often take several weeks to be effective. C Determine the amount of weight the client has lost since increasing activity. D Ask the client to describe the exercise schedule that he has been following. C Determine the amount of weight the client has lost since increasing activity. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? BSN 225 BSN 225 A Bend the arm by flexing the ulnar to the humerus. B Turn the head to the right and left. C Tilt the pelvis forwards and backwards. D Extend the arm at the side and rotate in circles. A Bend the arm by flexing the ulnar to the humerus. A client chronic fecal incontinence is crying because of embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement? A Administer a glycerin suppository 15 minutes after meals. B Assist a bedside commode 30 minutes after meals. C Encourage the use of incontinence briefs. D Insert a rectal tube at specified intervals. B Assist a bedside commode 30 minutes after meals. The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document? A Crackles. B Stridor. C Pleural rub. D Wheezing. A. Crackles. The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first? A. Respiratory rate. B. Temperature. C. Blood pressure. D. Pulse rate. A. Respiratory rate. The nurse is providing safety instructions to a client who is being discharged home with oxygen therapy. Which information provided by the client indicates understanding? A Avoid direct skin contact. B Remove tubing while eating. C Place a pad around the tank. D Keep the tank in a cool place. C. Place a pad around the tank. A 16-year-old emancipated client is being seen in the emergency department following a minor automobile. The client’s parents arrive and are asking questions about the client’s laboratory results. Which response is best for the nurse to provide? A. “I can only give medical information to your child because they are legally an adult.” B. “The healthcare provider will share this information with you.” C. “I can give you those results as soon as I get them back from the lab.” BSN 225 BSN 225 D. “I’m sorry, but your child’s medical information is none of your business.” B. "The healthcare provider will share this information with you." The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first? A. Use drawings that are universal for all cultures. B. Request a family member to remain with the client. C. Obtain a staff member who is a bilingual interpreter. D. Ask for the support of one of the client’s friends. C. Obtain a staff member who is a bilingual interpreter. A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? Select all that apply. A Provides comfort, dignity, and emotional support. B A living will becomes invalid when receiving hospice care. C Hospice services can be initiated prior to discharge. D Family members can be involved in the plan of care. E Can be provided within comforts of home. A. Provides comfort, dignity, and emotional support. C. Hospice services can be initiated prior to discharge. D. Family members can be involved in the plan of care. E. Can be provided within comforts of home. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? A Vary sites for temperature measurement. B Assess for flushed, warm skin regularly. C Measure temperature at regular intervals. D Document the client's circadian rhythms. A. Vary sites for temperature measurement. The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly remove the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take? A Reinsert the peripheral IV catheter. B Assess capillary refill distal to the restraints. C Verify that the restraints can be quickly released. D Replace the nasogastric tube. B Assess capillary refill distal to the restraints. The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus? A Motivational phrases. BSN 225 BSN 225 B Positive external places. C Emotional reflection. D Tranquil sounds. D Tranquil sounds. The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly? A A well approximated incision site. B Erythema and serosanguineous exudate. C Beefy red granulation tissue. D Eschar and slough in the wound. A. A well approximated incision site. An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply. A Ask the healthcare provider for a mild sedative for bedtime. B Avoid drinking caffeinated beverages late in the day. C Establish a regular time for going to bed and getting up. D Take an afternoon nap to make up for missed sleep. E Drink a mixture of warm water, whiskey, and honey at bedtime. B. Avoid drinking caffeinated beverages late in the day. C. Establish a regular time for going to bed and getting up. The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client’s spouse. In planning care, which nursing problem has the highest priority? A Fluid volume deficit. B Bowel incontinence. C Impaired had mobility. D Caregiver role strain. A Fluid volume deficit. An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take? A Before changing assignments, determine which staff members have fitted particulate filter masks. B Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client. C Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. BSN 225 BSN 225 D Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care. A Before changing assignments, determine which staff members have fitted particulate filter masks. A client is in contact isolation due to a stage IV coccyx would infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client’s room. In which order should the nurse perform the interventions? A Perform tracheostomy care, change coccyx dressing, restart the IV line. B Change coccyx dressing, restart the IV line, perform tracheostomy care. C Restart the IV line, perform tracheostomy care, change coccyx dressing. D Change coccyx dressing, perform tracheostomy care, restart the IV line. B Change coccyx dressing, restart the IV line, perform tracheostomy care. A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take? A Review the advanced directive document. B Irrigate the nasogastric tube with water. C Elevate the head of the bed 45 degrees. D Perform oropharyngeal suctioning. C Elevate the head of the bed 45 degrees. The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray implement? A Determine which member of the nursing staff brought the cup of coffee to the client. B Remind the client no milk or creamer can be added to the coffee. C Remove the coffee from the tray, advising the client that it is not included in the diet. D Consult with the dietitian to learn if the client is allowed to drink coffee. B Remind the client no milk or creamer can be added to the coffee. The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement? A Empty the sample into the 24 hour container. B Begin the collection the next day. C Observe the sample for sediment. D Start collecting the specimen with the next void. B Begin the collection the next day. The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement? A Switch to a non-rebreather mask. BSN 225 BSN 225 B Remove nasal cannula. C Verify placement of pulse oximeter. D Increase the oxygen to 3 L/minute. D Increase the oxygen to 3 L/minute. A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage? A Stress reduction. B Low-fat diet. C Regular exercise D Smoking cessation. D Smoking cessation. The client requesting juice to take with a buccal medication dose. Which action should the nurse implement? A Tell the client to place the medication under the tongue. B Instill the medication drops directly onto the conjunctiva. C Instructs client to place tablet between the check and gum. D Cleanse the skin area and apply the medication. C Instructs client to place tablet between the check and gum. The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first? A Monitor the client’s nonverbal behavior. B Review the pain medication prescribed. C Administer PRN oral pain medication. D Ask the client what is causing the grimacing. D Ask the client what is causing the grimacing. The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time? A Impaired physical mobility. B Self-care deficit. C Risk for infection. D Risk for impaired skin integrity. D Risk for impaired skin integrity. The nurse is demonstrating three-point crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking? A Practices bicep and triceps isometric exercises. B Progresses to foot touchdown and weight bearing of affected leg. BSN 225 BSN 225 C Bears body weight on the palms of hands during the crutch gait. D Inspects crutches to ensure rubber tips are intact. C Bears body weight on the palms of hands during the crutch gait. A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first? A Remind the spouse that the client may still live a long time. B Encourage the spouse to share their feelings. C Explain that alternative treatment options may be helpful. D Offer reassurance that the spouse is not alone. B Encourage the spouse to share their feelings. The nurse is entering a client’s presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first? A Wait for notification that the system has been rebooted. B Notify information services department of the situation. C Print electronic medical record (EMR) from backup server. D Identify information as late entry in the record. D Identify information as late entry in the record. The nurse reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in the client’s plan of care? Select all that apply. A Encourage increased fluid intake and measure urinary output every 8 hours. B Provide comfort measures such as topical warm application and tactile massage. C Assist the client to ambulate as much as possible during waking hours. D Implement a 24 hour schedule of routine administration of prescribed analgesic. E Determine client’s subjective measure of pain using a numerical pain scale. B Provide comfort measures such as topical warm application and tactile massage. C Assist the client to ambulate as much as possible during waking hours. D Implement a 24 hour schedule of routine administration of prescribed analgesic. E Determine client's subjective measure of pain using a numerical pain scale. It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem? A Urinary incontinence. B Weakened cough effort. C Plus two ankle edema. D Hypoactive bowel sounds. A Urinary incontinence. A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) BSN 225 BSN 225 infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply. A. Use standard precautions and wear a mask. B. Monitor the client’s white blood cell count. C Send wound drainage for culture and sensitivity. D Institute contact precautions for staff and visitors. E Explain the purpose of a low bacteria diet. B. Monitor the client's white blood cell count. C Send wound drainage for culture and sensitivity. D Institute contact precautions for staff and visitors. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly. B Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails. The nurse identifies a potential for infection in a client with partial-thickness (second degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns B Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection. The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level BSN 225 BSN 225 C. High hemoglobin level D. High cholesterol level A Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not 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. C Rationale: The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed. The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months B Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such 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 procedure is best for the nurse to follow? BSN 225 BSN 225 A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting 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. B Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall. Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back. A, B Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E). The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then 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." B Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol BSN 225 BSN 225 medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from 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. D Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? 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." A Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider .A Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL BSN 225 BSN 225 B. 0.8 mL C. 1.25 mL D. 2.0 mL B Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx. A, D Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E). The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt. B Rationale: His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? A. Self-care deficit B. Functional incontinence BSN 225 BSN 225 C. Fluid volume deficit D. High risk for infection D Rationale: Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill. A Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle. D Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers. A Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection. BSN 225 BSN 225 When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen. C Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings. D Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading. A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. BSN 225 BSN 225 D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved. C Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown. When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence. D Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it. The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate. A Rationale: Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the BSN 225 BSN 225 priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety. A client becomes angry while waiting