HESI NCLEX-RN Fundamentals
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?
(ANS- Taking anticoagulants for the past year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a
threat for developing surgical complications. The healthcare provider should be
informed that the client is taking such drugs.
Urinary catheterization is prescribed for a postoperative female client who has
been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen
in the tubing. What action will the nurse take next?
(ANS- Leave the catheter in place and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving
the first catheter in place will help locate the meatus when attempting the second
catheterization
The nurse is instructing a male 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?
(ANS- Compress the inhaler while slowly breathing in through your mouth.
Rationale:
The medication should be inhaled through the mouth simultaneously with
compression of the inhaler
,The nurse is assisting a male client to the bathroom. When 5 feet from the
bathroom door, the client states, "I feel faint." Before the nurse can get him to a
chair, he starts to fall. What is the priority action for the nurse to take?
(ANS- Gently lower the client to the floor.
Rationale:
(D) is the most prudent intervention and is the priority nursing action to prevent
injury to the client and the nurse. Lowering the client to the floor should be done
when the client cannot support his own weight. The client should be placed in a
bed or chair only when sufficient help is available to prevent injury.
Which nursing diagnosis has the highest priority when planning care for a client
with an indwelling urinary catheter?
(ANS- High risk for infection
Rationale:
Indwelling urinary catheters are a major source of infection
A nurse is working in an occupational health clinic when a male employee walks
in and states that he was struck by lightning while working on his truck bed. He is
alert but reports feeling faint. What assessment will the nurse perform first?
(ANS- Pulse characteristics
Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so
assessment of the pulse rate and regularity (A) is a priority. Since the client is
talking, he has an open airway
The nurse makes the nursing diagnosis of Potential for infection related to partial-
thickness (second-degree) and full-thickness (third-degree) burns. What
, intervention has the highest priority in decreasing the client's risk of infection?
(ANS- Use of careful handwashing technique
Rationale:
Careful handwashing technique (B) is the single most effective intervention for
prevention of contamination to all clients.
When taking a client's blood pressure, the nurse is unable to distinguish the point at
which the first sound was heard. What is the best action for the nurse to take?
(ANS- Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the
reading.
Rationale:
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the
extremity so that an accurate reading can be obtained on that extremity a second
time.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure in the lower extremity. Which observation of this procedure requires the
nurse's intervention?
(ANS- The UAP auscultates the popliteal pulse with the cuff on the lower leg.
Rationale:
When obtaining the blood pressure in the lower extremities, the popliteal pulse is
the site for auscultation when the blood pressure cuff is applied around the thigh.
The nurse should intervene with the UAP who has applied the cuff on the lower leg
In taking a client's history, the nurse asks about the stool characteristics. Which
description should the nurse report to the healthcare provider as soon as possible?
(ANS- Daily black, sticky stool
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?
(ANS- Taking anticoagulants for the past year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a
threat for developing surgical complications. The healthcare provider should be
informed that the client is taking such drugs.
Urinary catheterization is prescribed for a postoperative female client who has
been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen
in the tubing. What action will the nurse take next?
(ANS- Leave the catheter in place and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving
the first catheter in place will help locate the meatus when attempting the second
catheterization
The nurse is instructing a male 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?
(ANS- Compress the inhaler while slowly breathing in through your mouth.
Rationale:
The medication should be inhaled through the mouth simultaneously with
compression of the inhaler
,The nurse is assisting a male client to the bathroom. When 5 feet from the
bathroom door, the client states, "I feel faint." Before the nurse can get him to a
chair, he starts to fall. What is the priority action for the nurse to take?
(ANS- Gently lower the client to the floor.
Rationale:
(D) is the most prudent intervention and is the priority nursing action to prevent
injury to the client and the nurse. Lowering the client to the floor should be done
when the client cannot support his own weight. The client should be placed in a
bed or chair only when sufficient help is available to prevent injury.
Which nursing diagnosis has the highest priority when planning care for a client
with an indwelling urinary catheter?
(ANS- High risk for infection
Rationale:
Indwelling urinary catheters are a major source of infection
A nurse is working in an occupational health clinic when a male employee walks
in and states that he was struck by lightning while working on his truck bed. He is
alert but reports feeling faint. What assessment will the nurse perform first?
(ANS- Pulse characteristics
Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so
assessment of the pulse rate and regularity (A) is a priority. Since the client is
talking, he has an open airway
The nurse makes the nursing diagnosis of Potential for infection related to partial-
thickness (second-degree) and full-thickness (third-degree) burns. What
, intervention has the highest priority in decreasing the client's risk of infection?
(ANS- Use of careful handwashing technique
Rationale:
Careful handwashing technique (B) is the single most effective intervention for
prevention of contamination to all clients.
When taking a client's blood pressure, the nurse is unable to distinguish the point at
which the first sound was heard. What is the best action for the nurse to take?
(ANS- Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the
reading.
Rationale:
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the
extremity so that an accurate reading can be obtained on that extremity a second
time.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure in the lower extremity. Which observation of this procedure requires the
nurse's intervention?
(ANS- The UAP auscultates the popliteal pulse with the cuff on the lower leg.
Rationale:
When obtaining the blood pressure in the lower extremities, the popliteal pulse is
the site for auscultation when the blood pressure cuff is applied around the thigh.
The nurse should intervene with the UAP who has applied the cuff on the lower leg
In taking a client's history, the nurse asks about the stool characteristics. Which
description should the nurse report to the healthcare provider as soon as possible?
(ANS- Daily black, sticky stool
