HESI NCLEX-RN Fundamentals Practice Questions well elaborated

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. - ANSWERSThe 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? 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 - ANSWERSUrinary 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? 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 - ANSWERSThe 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? 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. - ANSWERSThe 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? High risk for infection Rationale: Indwelling urinary catheters are a major source of infection - ANSWERSWhich nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? 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 - ANSWERSA 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? Use of careful handwashing technique Rationale: Careful handwashing technique (B) is the single most effective intervention for prevention of contamination to all clients. - ANSWERSThe 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? 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. - ANSWERSWhen 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? 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 - ANSWERSThe 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? Daily black, sticky stool Rationale: Black, sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the healthcare provider promptly - ANSWERSIn 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? Ask the client to describe the routine he is currently following. Rationale: The nurse should first evaluate whether the client has been adhering to the original instructions - ANSWERSThe nurse is teaching a male client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep despite following the same routine every night. What action should the nurse take first? Mode of transmission Rationale: The contaminated gloves serve as the mode of transmission - ANSWERSBy rolling contaminated gloves inside out, the nurse is impacting which step in the chain of infection? Contact the healthcare provider to renew the prescription for the medication. Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the healthcare provider if the antihypertensive medication is not included in the postoperative prescriptions - ANSWERSThe nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication prescribed preoperatively is not listed. What action should the nurse take? Check the bath water temperature. Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature - ANSWERSIn assisting an older adult client prepare to take a tub bath, which nursing action is most important? Inform the surgeon the operative permit is not signed and the client has questions about the surgery. Rationale: The surgeon should be informed immediately that the permit is not signed - ANSWERSIn 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. What action should the nurse take next? Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care - ANSWERSA hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. What action by the nurse is best? Calmly reassure the client that the discomfort will be temporary. Rationale: The nurse should respond with a calm demeanor (C) to help reduce the client's apprehension. After responding calmly to the client's apprehension - ANSWERSAfter the nurse tells an older male client that an IV line needs to be inserted, he becomes very apprehensive, loudly verbalizing his dislike for all healthcare providers and nurses. How should the nurse respond? Discuss the importance of personal hygiene during menstruation with the client. Rationale: Since a shower is most beneficial for the client in terms of hygiene and mobility, the client should receive teaching first (D), respecting any personal beliefs, such as cultural or spiritual values. - ANSWERSA 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." What action should the nurse take first? If informed consent is withheld from a client, healthcare providers could be found guilty of negligence. Rationale: Healthcare providers may be found guilty of negligence (D), specifically, assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so (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 - ANSWERSWhen the healthcare 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. What legal principle is the court most likely to uphold regarding this client's right to informed consent? Assess the client's medical record to determine the client's normal bowel pattern. Rationale: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention ( - ANSWERSA client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? Record the amount on the client's fluid output record. Rationale: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output (A), but no additional action is needed - ANSWERSWhen emptying 350 ml of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. What action should the nurse take next? A Roman Catholic woman considering an abortion Rationale: In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may place the client at risk for spiritual distress - ANSWERSWhich client is most likely to be at risk for spiritual distress? Standing on his spouse's weak side, the caregiver provides security by holding the gait belt from the back. Rationale: The spouse is most likely to lean toward the weak side and needs extra support on that side and from the back (B) to prevent falling. - ANSWERSThe nurse teaches the use of a gait belt to a male caregiver whose spouse 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? Decrease intake of fluids after the evening meal. Rationale: Nocturia is urination during the night. (A) is helpful to decrease the production of urine, thus decreasing the need to void at night. - ANSWERSA client has a nursing diagnosis of, "Altered sleep patterns related to nocturia." Which client instruction is important for the nurse to provide? Stay with the client when he is in a standing position. Rationale: Although all of these measures are important, (A) is most important because it helps to ensure client safety. - ANSWERSThe nurse is obtaining a lie-sit-stand blood pressure reading on a male client. Which action is most important for the nurse to implement? Do not give the medication and document the reason. Rationale: The nurse should not give the medication and document the reason (C) because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent - ANSWERSThe nurse preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. What action should the nurse take? Assess the client's neurologic status. Rationale: This statement may indicate the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status (B) to be sure the client understands and can legally provide consent for surgery. - ANSWERSTen minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? Broiled fish, green beans, and an apple Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low fat diet, such as - ANSWERSThe nurse is instructing a client with cholecystitis regarding diet choices. What meal best meets the dietary needs of this client? Decreasing Cholesterol Levels Through Diet Rationale: A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. - ANSWERSThe nurse is teaching an obese female client, newly diagnosed with arteriosclerosis, about reducing her risk of a heart attack or stroke. What health promotion brochure is most important for the nurse to provide to this client? Description of the family's home environment Rationale: School-aged children often resist bedtime. The nurse should begin by assessing the environment of the home (D) to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. - ANSWERSDuring a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. What assessment data should the nurse obtain in response to the mother's report? Retract the foreskin gently to cleanse the penis. Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria ( - ANSWERSWhen bathing an uncircumcised male child over the age of 3, what action should the nurse take? Talk to the client and attempt to find out why the client is crying. Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed - ANSWERSThe nurse finds a client crying behind a locked bathroom door. The client will not open the door. What action should the nurse implement first? Check for kinks in the tubing and raise the IV pole. Rationale: The nurse should first check the tubing and height of the bag on the IV pole (B), which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel - ANSWERSThe nurse assesses a 2-year-old who is admitted for dehydration and finds the peripheral IV rate by gravity has slowed even though the venous access site is healthy. What should the nurse do next? Put the bed rails up on the opposite side. Rationale: Since 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 - ANSWERSWhen turning an immobile bedfast client without assistance, which action by the nurse best ensures client safety? Sodium Rationale: Monitoring of serum sodium levels (D) for hyponatremia is indicated during prolonged NG suctioning. - ANSWERSWhich serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? Compare the current reading with the client's previously documented blood pressure readings. Rationale: Comparing this reading with previous readings (D) will provide information about what is normal for this client: this action should be taken first. - ANSWERSA client's blood pressure reading is 156/94. What action should the nurse take first? The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. Rationale: Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect - ANSWERSThe healthcare provider has changed a client's prescription from the PO to IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? Change positions in the chair at least every hour. Rationale: The most important teaching is to change positions frequently (B), since pressure is the most significant factor related to the development of pressure ulcers. - ANSWERSA 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? Encourage the client to call the clinic nurse or healthcare provider if any questions should arise. Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or healthcare provider (D) if any questions should arise. - ANSWERSAfter receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a male client asks the nurse what he should do if he has questions about the medication when he gets home. How should the nurse respond? Sit facing the client. Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client (A), which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, - ANSWERSWhich nonverbal action should the nurse implement to demonstrate active listening? The ANA's Scope and Standards of Nursing Practice Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing (C) serves to direct the philosophy and standards of psychiatric nursing practice. - ANSWERSA community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? Inject the needle at a 90-degree angle. Rationale: Injecting the needle at a 90-degree angle allows the medication to be injected into the muscle, so that appropriate absorption can occur - ANSWERSWhen administering an intramuscular injection, which factor is most important to ensure the best medication absorption? Maintain standard precautions. Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing - ANSWERSBased on the nursing diagnosis of Risk for infection, which intervention is best for the nurse to implement when providing care for an elderly incontinent client? Encourage the client to see the clinic's grief counselor. Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the most important intervention for the nurse to implement. - ANSWERSWhile conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. What action is most important for the nurse to implement? 16 The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Since it was counted for 30 seconds, the rate should be doubled - ANSWERSThe nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. What respiratory rate should the nurse document? Select another sterile needle. Rationale: After a needlestick, the needle is considered used, so the nurse should discard it and select another needle (B). Since the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report (A) or notify the occupational health nurse - ANSWERSAfter a needlestick occurs while removing the cap from a sterile needle, what action should the nurse implement? Discard the saline solution and obtain a new, unopened bottle. 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 - ANSWERSWhen 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. What is the best action for the nurse to take? Water intoxication Rationale: Tap water is a hypotonic fluid that can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication (D). This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress. - ANSWERSAn older female client calls the clinic and states she feels very weak and dizzy. Further assessment by the nurse indicates that the client self-administered an enema of 3 L of tap water because she felt constipated. What is the most likely cause of the client's symptoms? 4, 3, 2, 1 Rationale: The nurse should first turn off the suction, then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction. - ANSWERSIn what sequence should the nurse implement these actions when giving medications to a client with a nasogastric tube that is connected to low intermittent suction? 1. Clamp the nasogastric tube. 2. Confirm placement of the tube. 3. Use a syringe to instill the medications. 4. Turn off the intermittent suction device. Speak directly to the client with an interpreter translating. Rationale: Wound care instructions should be given directly to the client by the nurse with an interpreter (B) who is trained to provide accurate and objective translation in the client's primary language, so the client has the opportunity to ask questions during the teaching process. - ANSWERSWhich action should the nurse implement when providing wound care instructions to a client who does not speak English?