HESI NCLEX-RN Exam (5th Ed.) - FUNDAMENTALS REVIEW REVISION 2024

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 C. High hemoglobin level D. High cholesterol level - answersA. 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. A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury - answersA. Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift - answersA. Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications. 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." - answersA. 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. 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 C. Fluid volume deficit D. High risk for infection - answersD. 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 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. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved. - answersC. 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. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before." - answersRationale: The client's recognition of a "new" pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client's feelings C should be acknowledged, but observation of the five rights of medication administration is most essential. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990 - answersC. Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise. - answersD. Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed. The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which interventions 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. - answersA, D. Rationale: Options 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. 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. 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. The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents - answersC. Rationale: The nurse should not give the medication and should document the reason 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 or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered. 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. - answersA. 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. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? 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. - answersB. 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. 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. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction. - answersC. 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 client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time. - answersD. Rationale: The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender or age, even when not using the client's name. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client. - answersD. Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules. 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. - answersC. 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. After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately. - answersRationale: After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. Because 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 or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity - answersB. Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns. - answersD. Rationale: Option D provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. Options A and B may not be related to her current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the concerns she is having. 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. - answersC. 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 male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control. - answersA. Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family." - answersC. Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time. 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 - answersB. 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. While 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. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications. - answersA. Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one. Which nonverbal action should the nurse implement to demonstrate active listening?