1. 1.ID: 9476872990
A registered nurse (RN) on the 7 a.m.–3 p.m. shift is planning client assignments for the day. Which
clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)? Select all
that apply.
A. A client who had a mastectomy 2 days ago Correct
B. A client with type 1 diabetes mellitus who has a foot ulcer Correct
C. A client with left-side weakness who will need assistance with personal care Correct
D. A newly admitted client with chronic obstructive pulmonary disease (COPD)
E. A client being transferred in from the intensive care unit with a deep vein thrombosis
and a heparin drip
Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse
assigning the task is responsible for ensuring that each task is appropriately assigned on the basis
of the educational level and competency of the staff member. The client with COPD who was
admitted during the night will need close monitoring of the respiratory status. An LPN may not
administer most high-risk intravenous medications, including heparin. The client who has had a
mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is
within the scope of practice of the LPN. The client with left-side weakness requiring personal care
assistance could also be assigned to the LPN.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to the
LPN. Recalling that an LPN may not administer high-risk intravenous medications will assist you in
eliminating this option. Eliminate the newly admitted client with COPD, noting that this client will
require a higher level of monitoring. Review the principles of delegating tasks if you had difficulty
with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., pp.
305, 308). St. Louis: Elsevier
Awarded 3.0 points out of 3.0 possible points.
2. 2.ID: 9476871061
A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum
(HEG). During physical assessment of the client, the nurse should first:
A. Weigh the client Incorrect
B. Assess the client’s intake and output Correct
C. Encourage the client to verbalize her feelings about the diagnosis
D. Review the results of the hemoglobin and hematocrit determinations
, Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It
can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis,
acid-base imbalance, and electrolyte imbalances. Physical assessment begins with determining the
client’s intake and output, because these data provide information regarding hydration and the
nutritional status of the client. The client’s weight would be obtained and the baseline value
compared with previous and subsequent values. Additionally, the nurse would instruct the client in
how to accurately check and monitor her weight. Laboratory data may need to be evaluated;
increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the
client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the
first intervention during physical assessment.
Test-Taking Strategy: Note the strategic word “first.” Use Maslow’s Hierarchy of Needs theory to
eliminate the option that indicates encouraging the client to verbalize her feelings, recalling that
physiological needs are the priority. To select from the remaining options, recall the description of
HEG; this will direct you to the correct option. Review the priority physical assessment techniques in
this disorder if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Nutrition
HESI Concepts: Collaboration/Managing Care – Care Coordination, Nutrition
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child
nursing (4th ed., pp. 589-590). St. Louis: Elsevier.
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 9476869315
A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed
assistive personnel (UAP)on the team and is planning the client assignments for the night. Which
client does the RN assign to the LPN? Select all that apply.
A. A client who undergoing a 24-hour urine collection Incorrect
B. A client with a nasogastric tube who underwent bowel resection 2 days ago Correct
C. A client with urinary frequency who needs assistance in getting to the bathroom
D. A client scheduled for renal dialysis in the morning who needs assistance with
hygiene
E. A client who has been fitted with skeletal traction of the right leg after an open
reduction measures Correct
Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse
assigning the task is responsible for ensuring that each task is appropriately assigned on the basis
of the educational level and competency of the staff member. An LPN may perform certain invasive
procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client
in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because
, the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for
postoperative complications that the clients will require. Interventions such as assisting clients with
ambulation and hygiene measures and performing noninvasive procedures — the types of tasks
identified in the other options — may be assigned to a nursing assistant.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to an
LPN. Eliminate the options that are comparable or alike in that they are noninvasive procedures.
Also note that the remaining options involve routine care of the postoperative client and activities
that are within the scope of practice for the LPN. Review the principles of delegation if you had
difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing.
(8th ed., pp. 262, 281-283). St. Louis: Mosby.
Awarded 1.0 points out of 2.0 possible points.
4. 4.ID: 9476867243
A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to
prevent seizures. The nurse notes that the client’s respiratory rate is 10 breaths/min. On the basis of
this finding, the nurse first:
A. Takes the client’s vital signs health care provider
B. Contacts the health care provider Incorrect
C. Discontinues the magnesium sulfate Correct
D. Checks the most recent serum magnesium sulfate level
Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity.Other signs
include the absence of deep tendon reflexes, altered sensorium, hypotension, and a serum
magnesium level above the therapeutic range of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this
situation, the nurse would first discontinue the magnesium sulfate. The nurse would then take the
client’s vital signs and contact the health care provider health care providerThe most recent serum
magnesium level may be checked; however, a current serum level would provide more useful data.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recalling
that a respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity will direct you to
the correct option. Review these signs and the appropriate nursing interventions if you had difficulty
with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Giddens Concepts: Clinical Judgment, Safety
, HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child
nursing (4th ed., p. 595). St. Louis: Elsevier.
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 9476864338
A client who has just undergone abdominal surgery calls the nurse and states, “I feel as if I just split
open.” The nurse checks the abdominal incision and finds wound evisceration. The
nurse immediately:
A. Documents the findings
B. Notifies the operating room
C. Takes the client’s vital signs
D. Contacts the health care provider Correct
Rationale: Wound evisceration is the total separation of a surgical incision or wound with extrusion of
the internal organs or viscera through the open wound. When evisceration occurs, the nurse
immediately calls for help and has the health care provider notified. The nurse stays with the client
and positions the client with the hips and knees bent. The nurse then covers the abdominal wound
with a sterile dressing moistened with sterile saline solution. The nurse would then take the client’s
vital signs and document the occurrence. Since this is a surgical emergency, the operating room
would be notified but this would not be done until directed to do so by the surgeon.
Test-Taking Strategy: Use the process of elimination and your prioritizing skills. Note the strategic
word “immediately.” Recalling that wound evisceration is a surgical emergency will direct you to the
correct option. Review the nursing actions to be taken immediately in the event of wound
evisceration occurs if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Caregiving
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cargiving
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 9476874711
A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline solution at a rate of 125
mL/hr. The client suddenly complains of shortness of breath, and the nurse notes the presence of
dependent edema and puffiness around the client’s eyes. The nurse suspects circulatory overload
and immediately:
A. Slows the IV rate Correct
B. Administers a diuretic
C. Contacts the health care provider
A registered nurse (RN) on the 7 a.m.–3 p.m. shift is planning client assignments for the day. Which
clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)? Select all
that apply.
A. A client who had a mastectomy 2 days ago Correct
B. A client with type 1 diabetes mellitus who has a foot ulcer Correct
C. A client with left-side weakness who will need assistance with personal care Correct
D. A newly admitted client with chronic obstructive pulmonary disease (COPD)
E. A client being transferred in from the intensive care unit with a deep vein thrombosis
and a heparin drip
Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse
assigning the task is responsible for ensuring that each task is appropriately assigned on the basis
of the educational level and competency of the staff member. The client with COPD who was
admitted during the night will need close monitoring of the respiratory status. An LPN may not
administer most high-risk intravenous medications, including heparin. The client who has had a
mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is
within the scope of practice of the LPN. The client with left-side weakness requiring personal care
assistance could also be assigned to the LPN.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to the
LPN. Recalling that an LPN may not administer high-risk intravenous medications will assist you in
eliminating this option. Eliminate the newly admitted client with COPD, noting that this client will
require a higher level of monitoring. Review the principles of delegating tasks if you had difficulty
with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., pp.
305, 308). St. Louis: Elsevier
Awarded 3.0 points out of 3.0 possible points.
2. 2.ID: 9476871061
A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum
(HEG). During physical assessment of the client, the nurse should first:
A. Weigh the client Incorrect
B. Assess the client’s intake and output Correct
C. Encourage the client to verbalize her feelings about the diagnosis
D. Review the results of the hemoglobin and hematocrit determinations
, Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It
can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis,
acid-base imbalance, and electrolyte imbalances. Physical assessment begins with determining the
client’s intake and output, because these data provide information regarding hydration and the
nutritional status of the client. The client’s weight would be obtained and the baseline value
compared with previous and subsequent values. Additionally, the nurse would instruct the client in
how to accurately check and monitor her weight. Laboratory data may need to be evaluated;
increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the
client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the
first intervention during physical assessment.
Test-Taking Strategy: Note the strategic word “first.” Use Maslow’s Hierarchy of Needs theory to
eliminate the option that indicates encouraging the client to verbalize her feelings, recalling that
physiological needs are the priority. To select from the remaining options, recall the description of
HEG; this will direct you to the correct option. Review the priority physical assessment techniques in
this disorder if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Nutrition
HESI Concepts: Collaboration/Managing Care – Care Coordination, Nutrition
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child
nursing (4th ed., pp. 589-590). St. Louis: Elsevier.
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 9476869315
A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed
assistive personnel (UAP)on the team and is planning the client assignments for the night. Which
client does the RN assign to the LPN? Select all that apply.
A. A client who undergoing a 24-hour urine collection Incorrect
B. A client with a nasogastric tube who underwent bowel resection 2 days ago Correct
C. A client with urinary frequency who needs assistance in getting to the bathroom
D. A client scheduled for renal dialysis in the morning who needs assistance with
hygiene
E. A client who has been fitted with skeletal traction of the right leg after an open
reduction measures Correct
Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse
assigning the task is responsible for ensuring that each task is appropriately assigned on the basis
of the educational level and competency of the staff member. An LPN may perform certain invasive
procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client
in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because
, the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for
postoperative complications that the clients will require. Interventions such as assisting clients with
ambulation and hygiene measures and performing noninvasive procedures — the types of tasks
identified in the other options — may be assigned to a nursing assistant.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to an
LPN. Eliminate the options that are comparable or alike in that they are noninvasive procedures.
Also note that the remaining options involve routine care of the postoperative client and activities
that are within the scope of practice for the LPN. Review the principles of delegation if you had
difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing.
(8th ed., pp. 262, 281-283). St. Louis: Mosby.
Awarded 1.0 points out of 2.0 possible points.
4. 4.ID: 9476867243
A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to
prevent seizures. The nurse notes that the client’s respiratory rate is 10 breaths/min. On the basis of
this finding, the nurse first:
A. Takes the client’s vital signs health care provider
B. Contacts the health care provider Incorrect
C. Discontinues the magnesium sulfate Correct
D. Checks the most recent serum magnesium sulfate level
Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity.Other signs
include the absence of deep tendon reflexes, altered sensorium, hypotension, and a serum
magnesium level above the therapeutic range of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this
situation, the nurse would first discontinue the magnesium sulfate. The nurse would then take the
client’s vital signs and contact the health care provider health care providerThe most recent serum
magnesium level may be checked; however, a current serum level would provide more useful data.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recalling
that a respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity will direct you to
the correct option. Review these signs and the appropriate nursing interventions if you had difficulty
with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Giddens Concepts: Clinical Judgment, Safety
, HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child
nursing (4th ed., p. 595). St. Louis: Elsevier.
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 9476864338
A client who has just undergone abdominal surgery calls the nurse and states, “I feel as if I just split
open.” The nurse checks the abdominal incision and finds wound evisceration. The
nurse immediately:
A. Documents the findings
B. Notifies the operating room
C. Takes the client’s vital signs
D. Contacts the health care provider Correct
Rationale: Wound evisceration is the total separation of a surgical incision or wound with extrusion of
the internal organs or viscera through the open wound. When evisceration occurs, the nurse
immediately calls for help and has the health care provider notified. The nurse stays with the client
and positions the client with the hips and knees bent. The nurse then covers the abdominal wound
with a sterile dressing moistened with sterile saline solution. The nurse would then take the client’s
vital signs and document the occurrence. Since this is a surgical emergency, the operating room
would be notified but this would not be done until directed to do so by the surgeon.
Test-Taking Strategy: Use the process of elimination and your prioritizing skills. Note the strategic
word “immediately.” Recalling that wound evisceration is a surgical emergency will direct you to the
correct option. Review the nursing actions to be taken immediately in the event of wound
evisceration occurs if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Caregiving
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cargiving
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 9476874711
A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline solution at a rate of 125
mL/hr. The client suddenly complains of shortness of breath, and the nurse notes the presence of
dependent edema and puffiness around the client’s eyes. The nurse suspects circulatory overload
and immediately:
A. Slows the IV rate Correct
B. Administers a diuretic
C. Contacts the health care provider
