CCRI NURSING 1010 HESI 1 NCLEX QUESTIONS
The nurse hears a client calling out for help, hurries down the hallway to the client's
room, and finds the client lying on the floor. The nurse performs an assessment, assists
the client back to bed, notifies the primary health care provider, and completes an
occurrence report. Which statement should the nurse document on the occurrence
report?
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get out of bed. - Answers - 16. Answer: 3
Rationale: The occurrence report should contain a factual description of the
occurrence, any injuries experienced by those involved, and the outcome of the
situation. The correct option is the only one that describes the facts as observed by
the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual
information as observed by the nurse.
A client is brought to the emergency department by emergency medical services (EMS)
after being hit by a car. The name of the client is unknown, and the client has sustained
a severe head injury and multiple fractures and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure, which is
the best action?
1. Obtain a court order for the surgical procedure.
2. Ask the EMS team to sign the informed consent.
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family. - Answers - 17. Answer: 3
Rationale: In general, there are two situations in which informed consent of an
adult client is not needed. One is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury or
death to the client. The second is when the client waives the right to give informed
consent. Option 1 will delay emergency treatment, and option 2 is inappropriate.
Although option 4 may be pursued, it is not the best action because it delays
necessary emergency treatment.
The nurse has just assisted a client back to bed after a fall. The nurse and primary
health care provider have assessed the client and have determined that the client is not
injured. After completing the occurrence report, the nurse should implement which
action next?
1. Reassess the client.
2. Conduct a staff meeting to describe the fall.
3. Contact the nursing supervisor to update information regarding
the fall.
,4. Document in the nurse's notes that an occurrence report was
completed. - Answers - Answer: 1
Rationale: After a client's fall, the nurse must frequently reassess the client,
because potential complications do not always appear immediately after the fall. The
client's fall should be treated as private information and shared on a "need to know"
basis. Communication regarding the event should involve only the individuals
participating in the client's care. An occurrence report is a problem-solving
document; however, its completion is not documented in the nurse's notes. If the
nursing supervisor has been made aware of the occurrence, the supervisor will
contact the nurse if status update is necessary.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for
the day because the ICU is understaffed and needs additional nurses to care for the
clients. The nurse has never worked in the ICU. The nurse should take which best
action?
1. Refuse to float to the ICU based on lack of unit orientation.
2. Clarify the ICU client assignment with the team leader to ensure
that it is a safe assignment.
3. Ask the nursing supervisor to review the hospital policy on
floating.
4. Submit a written protest to nursing administration, and then call
the hospital lawyer. - Answers - Answer: 2
Rationale: Floating is an acceptable practice used by hospitals to solve
understaffing problems. Legally, the nurse cannot refuse to float unless a union
contract guarantees that nurses can work only in a specified area or the nurse can
prove the lack of knowledge for the performance of assigned tasks. When
encountering this situation, the nurse should set priorities and identify potential
areas of harm to the client. That is why clarifying the client assignment with the team
leader to ensure that it is a safe one is the best option. The nursing supervisor is
called if the nurse is expected to perform tasks that he or she cannot safely perform.
Submitting a written protest and calling the hospital lawyer is a premature action.
The nurse who works on the night shift enters the medication room and finds a
coworker with a tourniquet wrapped around the upper arm. The coworker is about to
insert a needle, attached to a syringe containing a clear liquid, into the antecubital area.
Which is the most appropriate action by the nurse?
1. Call security.
2. Call the police.
3. Call the nursing supervisor.
4. Lock the coworker in the medication room until help is obtained. - Answers - Answer:
3
Rationale: Nurse practice acts require reporting impaired nurses. The board of
nursing has jurisdiction over the practice of nursing and may develop plans for
treatment and supervision of the impaired nurse. This occurrence needs to be
,reported to the nursing supervisor, who will then report to the board of nursing and
other authorities, such as the police, as required. The nurse may call security if a
disturbance occurs, but no information in the question supports this need, and so
this is not the appropriate action. Option 4 is an inappropriate and unsafe action.
A hospitalized client tells the nurse that an instructional directive is being prepared and
that the lawyer will be bringing the document to the hospital today for witness
signatures. The client asks the nurse for assistance in obtaining a witness to the will.
Which is the most appropriate response to
the client?
1. "I will sign as a witness to your signature."
2. "You will need to find a witness on your own."
3. "Whoever is available at the time will sign as a witness for you."
4. "I will call the nursing supervisor to seek assistance regarding
your request." - Answers - Answer: 4
Rationale: Instructional directives (living wills) are required to be in writing and
signed by the client. The client's signature must be witnessed by specified
individuals or notarized. Laws and guidelines regarding instructional directives
vary from state to state, and it is the responsibility of the nurse to know the laws.
Many states prohibit any employee, including the nurse of a facility where the client
is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful
response. The nurse should seek the assistance of the nursing supervisor.
The nurse has made an error in documentation of the dose administered of an opioid
pain medication in the client's record. The nurse draws 1 mg from the vial and another
registered nurse (RN) witnesses wasting of the
remaining 1 mg. When scanning the medication, the nurse entered into the medication
administration record (MAR) that 2 mg of hydromorphone was administered instead of
the actual dose administered, which was 1 mg. The
nurse should take which action(s) to correct the error in the MAR? Select all that apply.
1. Complete and file an occurrence report.
2. Right-click on the entry and modify it to reflect the correct
information.
3. Document the correct information and end with the nurse's
signature and title.
4. Obtain a cosignature from the RN who witnessed the waste of
the remaining 1 mg.
5. Document in a nurse's note in the client's record detailing the
corrected information. - Answers - Answer: 2, 3, 4, 5
Rationale: Electronic health records (EHR) will have a time date stamp that
indicates an amendment has been entered. If the nurse makes an error in the MAR,
the nurse should follow agency policies to correct the error. In the MAR, the nurse
can click on the entry (usually right-click) and modify it to reflect the corrected
information. Since this is an opioid medication, the nurse should obtain a
, cosignature from the RN who witnessed the wasting of the excess medication, to
validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to
detail the event and the corrections made, and the nurse's name and title will be
stamped on the entry in the EHR. An occurrence report is not necessary in this
situation.
Nursing staff members are sitting in the lounge taking their morning break.
An assistive personnel (AP) tells the group that she thinks that the unit
secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to
tell the nursing staff that the secretary probably contracted the disease from
her husband, who is supposedly a drug addict. The registered nurse should
inform the AP that making this accusation has violated which legal tort?
1. Libel
2. Slander
3. Assault
4. Negligence - Answers - Answer: 2
Rationale: Defamation is a false communication or a careless disregard for the
truth that causes damage to someone's reputation, either in writing (libel) or
verbally (slander). An assault occurs when a person puts another person in fear of a
harmful or offensive contact. Negligence involves the actions of professionals that
fall below the standard of care for a specific professional group.
An older woman is brought to the emergency department for treatment of a
fractured arm. On physical assessment, the nurse notes old and new
ecchymotic areas on the client's chest and legs and asks the client how the
bruises were sustained. The client, although reluctant, tells the nurse in
confidence that her son frequently hits her if supper is not prepared on time
when he arrives home from work. Which is the most appropriate nursing
response?
1. "Oh, really? I will discuss this situation with your son."
2. "Let's talk about the ways you can manage your time to prevent
this from happening."
3. "Do you have any friends who can help you out until you resolve
these important issues with your son?"
4. "As a nurse, I am legally bound to report abuse. I will stay with
you while you give the report and help find a safe place for you to
stay." - Answers - Answer: 4
Rationale: The nurse must report situations related to child or elder abuse,
gunshot wounds and other criminal acts, and certain infectious diseases.
Confidential issues are not to be discussed with nonmedical personnel or the client's
family or friends without the client's permission. Clients should be assured that
information is kept confidential, unless it places the nurse under a legal obligation.
Options 1, 2, and 3 do not address the legal implications of the situation and do not
ensure a safe environment for the client.
The nurse hears a client calling out for help, hurries down the hallway to the client's
room, and finds the client lying on the floor. The nurse performs an assessment, assists
the client back to bed, notifies the primary health care provider, and completes an
occurrence report. Which statement should the nurse document on the occurrence
report?
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get out of bed. - Answers - 16. Answer: 3
Rationale: The occurrence report should contain a factual description of the
occurrence, any injuries experienced by those involved, and the outcome of the
situation. The correct option is the only one that describes the facts as observed by
the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual
information as observed by the nurse.
A client is brought to the emergency department by emergency medical services (EMS)
after being hit by a car. The name of the client is unknown, and the client has sustained
a severe head injury and multiple fractures and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure, which is
the best action?
1. Obtain a court order for the surgical procedure.
2. Ask the EMS team to sign the informed consent.
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family. - Answers - 17. Answer: 3
Rationale: In general, there are two situations in which informed consent of an
adult client is not needed. One is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury or
death to the client. The second is when the client waives the right to give informed
consent. Option 1 will delay emergency treatment, and option 2 is inappropriate.
Although option 4 may be pursued, it is not the best action because it delays
necessary emergency treatment.
The nurse has just assisted a client back to bed after a fall. The nurse and primary
health care provider have assessed the client and have determined that the client is not
injured. After completing the occurrence report, the nurse should implement which
action next?
1. Reassess the client.
2. Conduct a staff meeting to describe the fall.
3. Contact the nursing supervisor to update information regarding
the fall.
,4. Document in the nurse's notes that an occurrence report was
completed. - Answers - Answer: 1
Rationale: After a client's fall, the nurse must frequently reassess the client,
because potential complications do not always appear immediately after the fall. The
client's fall should be treated as private information and shared on a "need to know"
basis. Communication regarding the event should involve only the individuals
participating in the client's care. An occurrence report is a problem-solving
document; however, its completion is not documented in the nurse's notes. If the
nursing supervisor has been made aware of the occurrence, the supervisor will
contact the nurse if status update is necessary.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for
the day because the ICU is understaffed and needs additional nurses to care for the
clients. The nurse has never worked in the ICU. The nurse should take which best
action?
1. Refuse to float to the ICU based on lack of unit orientation.
2. Clarify the ICU client assignment with the team leader to ensure
that it is a safe assignment.
3. Ask the nursing supervisor to review the hospital policy on
floating.
4. Submit a written protest to nursing administration, and then call
the hospital lawyer. - Answers - Answer: 2
Rationale: Floating is an acceptable practice used by hospitals to solve
understaffing problems. Legally, the nurse cannot refuse to float unless a union
contract guarantees that nurses can work only in a specified area or the nurse can
prove the lack of knowledge for the performance of assigned tasks. When
encountering this situation, the nurse should set priorities and identify potential
areas of harm to the client. That is why clarifying the client assignment with the team
leader to ensure that it is a safe one is the best option. The nursing supervisor is
called if the nurse is expected to perform tasks that he or she cannot safely perform.
Submitting a written protest and calling the hospital lawyer is a premature action.
The nurse who works on the night shift enters the medication room and finds a
coworker with a tourniquet wrapped around the upper arm. The coworker is about to
insert a needle, attached to a syringe containing a clear liquid, into the antecubital area.
Which is the most appropriate action by the nurse?
1. Call security.
2. Call the police.
3. Call the nursing supervisor.
4. Lock the coworker in the medication room until help is obtained. - Answers - Answer:
3
Rationale: Nurse practice acts require reporting impaired nurses. The board of
nursing has jurisdiction over the practice of nursing and may develop plans for
treatment and supervision of the impaired nurse. This occurrence needs to be
,reported to the nursing supervisor, who will then report to the board of nursing and
other authorities, such as the police, as required. The nurse may call security if a
disturbance occurs, but no information in the question supports this need, and so
this is not the appropriate action. Option 4 is an inappropriate and unsafe action.
A hospitalized client tells the nurse that an instructional directive is being prepared and
that the lawyer will be bringing the document to the hospital today for witness
signatures. The client asks the nurse for assistance in obtaining a witness to the will.
Which is the most appropriate response to
the client?
1. "I will sign as a witness to your signature."
2. "You will need to find a witness on your own."
3. "Whoever is available at the time will sign as a witness for you."
4. "I will call the nursing supervisor to seek assistance regarding
your request." - Answers - Answer: 4
Rationale: Instructional directives (living wills) are required to be in writing and
signed by the client. The client's signature must be witnessed by specified
individuals or notarized. Laws and guidelines regarding instructional directives
vary from state to state, and it is the responsibility of the nurse to know the laws.
Many states prohibit any employee, including the nurse of a facility where the client
is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful
response. The nurse should seek the assistance of the nursing supervisor.
The nurse has made an error in documentation of the dose administered of an opioid
pain medication in the client's record. The nurse draws 1 mg from the vial and another
registered nurse (RN) witnesses wasting of the
remaining 1 mg. When scanning the medication, the nurse entered into the medication
administration record (MAR) that 2 mg of hydromorphone was administered instead of
the actual dose administered, which was 1 mg. The
nurse should take which action(s) to correct the error in the MAR? Select all that apply.
1. Complete and file an occurrence report.
2. Right-click on the entry and modify it to reflect the correct
information.
3. Document the correct information and end with the nurse's
signature and title.
4. Obtain a cosignature from the RN who witnessed the waste of
the remaining 1 mg.
5. Document in a nurse's note in the client's record detailing the
corrected information. - Answers - Answer: 2, 3, 4, 5
Rationale: Electronic health records (EHR) will have a time date stamp that
indicates an amendment has been entered. If the nurse makes an error in the MAR,
the nurse should follow agency policies to correct the error. In the MAR, the nurse
can click on the entry (usually right-click) and modify it to reflect the corrected
information. Since this is an opioid medication, the nurse should obtain a
, cosignature from the RN who witnessed the wasting of the excess medication, to
validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to
detail the event and the corrections made, and the nurse's name and title will be
stamped on the entry in the EHR. An occurrence report is not necessary in this
situation.
Nursing staff members are sitting in the lounge taking their morning break.
An assistive personnel (AP) tells the group that she thinks that the unit
secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to
tell the nursing staff that the secretary probably contracted the disease from
her husband, who is supposedly a drug addict. The registered nurse should
inform the AP that making this accusation has violated which legal tort?
1. Libel
2. Slander
3. Assault
4. Negligence - Answers - Answer: 2
Rationale: Defamation is a false communication or a careless disregard for the
truth that causes damage to someone's reputation, either in writing (libel) or
verbally (slander). An assault occurs when a person puts another person in fear of a
harmful or offensive contact. Negligence involves the actions of professionals that
fall below the standard of care for a specific professional group.
An older woman is brought to the emergency department for treatment of a
fractured arm. On physical assessment, the nurse notes old and new
ecchymotic areas on the client's chest and legs and asks the client how the
bruises were sustained. The client, although reluctant, tells the nurse in
confidence that her son frequently hits her if supper is not prepared on time
when he arrives home from work. Which is the most appropriate nursing
response?
1. "Oh, really? I will discuss this situation with your son."
2. "Let's talk about the ways you can manage your time to prevent
this from happening."
3. "Do you have any friends who can help you out until you resolve
these important issues with your son?"
4. "As a nurse, I am legally bound to report abuse. I will stay with
you while you give the report and help find a safe place for you to
stay." - Answers - Answer: 4
Rationale: The nurse must report situations related to child or elder abuse,
gunshot wounds and other criminal acts, and certain infectious diseases.
Confidential issues are not to be discussed with nonmedical personnel or the client's
family or friends without the client's permission. Clients should be assured that
information is kept confidential, unless it places the nurse under a legal obligation.
Options 1, 2, and 3 do not address the legal implications of the situation and do not
ensure a safe environment for the client.
