HESI RN FUNDAMENTALS TESTBANK
q q q
AqpostoperativeqclientqhasqthreeqdifferentqPRNqanalgesicsqprescribedqforqdifferentqlevelsqofqpain.qT
heqnurseqinadvertentlyadministerqaqdoseqthatqisqnotqwithinqtheqprescribedqparameters.qWhatqact
ionqshouldqtheqnurseqtakeqfirst?q C
A) Determineqifqtheqpainqwasqrelieved.
B) Completeqaqmedicationqerrorqreport.
C) Assessqforq sideqeffectsq ofq theq medication.
D) Documentq theq client’sq responses.
Thequnlicensedqassistiveqpersonnelq(UAP)qdescribesqtheqappearanceqofqtheqbowelqmovem
entsqofqseveralqclients.qWhichqdescriptionsqwarrantqadditionalqfollow-
upqbyqtheqnurse?q(Selectqallqthatqapply.)ABDE
A) Multipleqhardqpellets.
B) Brownq liquid.
C) Formedqbutqsoft.
D) Solidqwithqredqstreaks
E) Tarryqappearance.
q
Anqelderlyqwomanqcomesqtoqtheqclinicqbecauseqofqvaginalqbleeding.qTheqhealthcareqproviderqfindsqaqvaginalqte
ar,qwhichqtheclientqreportsqisqlikelyqtoqhaveqoccurredqduringqunprotectedqsexualqintercourse.qWhichqcontentqisq
mostqimportantqforqtheqnurseqtoqincludeqinqthisqclient’sqteachingqplan? A
A) Theqimportanceq ofq usingq vaginalq lubricants.
B) Methodsqusedqtoqpracticeqsafeqsex.
C) Informationqaboutqalternativeqwaysqtoqexpressqsexuality.
D) Intercourseqpositionsqthatqhelpqpreventqtears.
Aqmaleq clientqhasqright-
sidedq hemiplegiaqfollowingq aq leftqcerebrovascularq accidentq(CVA).qHisqsittingqbalanceqhasqimpro
ved,qandqheqisqnowqableqtoqsitqinqaqwheelchair.qToqassistqtheqclientqin
, transferringqfromqtheqbedqtoqaqwheelchair,qwhatqactionqshouldtheqnurseqtake?
A) Haveqtheqclientqputqbothqarmsqaroundqtheqnurse’sqneckqforqsupport
B) Placetheqwheelchairqonqtheqclient’sqleftqside.
C) Instructqtheqclientqtoqlookqatqhisqfeet.
D) Instructqtheqclientqtotalqslow,qdeepqbreathsqwhileqtransferring.
Theqnurseqobservesqaqnewlyqadmittedqolderqadultqfemaleqtakeqshortqstepsqandqwalkqveryqslow
lyqwhileqpushingqaq walkerqinfrontqofqher.qWhatqactionqshouldqtheqnurseqtakeqinqresponseqtoqth
eseqobservations? A
A) Completeqaqfullqfallqriskqassessmentqofqtheqclient.
B) Teachq theqclientq toq takeq longerq stepsq atq fasterq pace.
C) Suggestqthatqtheqclientquseqaqwheelchairqinsteadqofqaqwalker.
D) Placeqclientqonqbedqrestquntilqtheqhealthcareqproviderqisqnotified.
Aqclientqisqreceivingqketorolacq(Toradol)qIMq45qmgqIMq6qhoursqforqpostoperativeqpain.qTheqavaila
bleq2qmlqvialqisqlabeled,ToradolqIMq30qmg/ml,qhowqmanyq shouldq theqnurseqadminister?q(Roundqt
oqtheqnearestqtenth.)q 1.5mg
Whileqsuctioningqaqclient’sqnasopharynx,qtheqnurseqobservesqthatqtheqclient’sqoxygenq
saturationqremainsqatq94%,qwhichqisqtheqsameqreadingqobtainedqpriorqtoqstartingqtheq
procedure.qWhatqactionqshouldqtheqnurseqtakeqinq responseqtoqthisqfinding?qC
A) Repositionqtheqpulseqoximeterqclipqtoqobtainqaqnewqreading.
B) Stopqsuctioningquntilqtheqpulseqoximeterqreadingqisqaboveq95%.
C) Completeqtheqintermittentqsuctionqofqtheqnasopharynx.
D) Applyqanqoxygenqmaskqoverqtheqclient’sqnoseqandqmouth.
Anqolderqwomanqwithqendqstageqheartqdiseaseqisqhospitalizedqforqsevereqheartqfailure.qSheqisqalert,qoriented,q
andqrequestsqthatnoqheroicqmeasuresqareqimplementedqifqherqbreathingqstops.qWhatqactionqshouldqtheqnur
seqtakeq first?qA
A) Discussqwithqtheqclientqherqmeaningqofqheroicqmeasures.
B) Obtainqaq“doqnotqresuscitate”q(DNR)qprescription.
, C) Setqupqaqfamilyqconferenceqtoqdiscussqtheqclient’s.
D) Consultqtheqpalliativeqcareqteamqaboutqclient’sqcare.
Aqclientqdiagnosedqwithqprimaryqopen-
angleqglaucomaqreceivedq aq prescriptionqforqbioticqeyeqdrops,qpilocarpineHCl(Pilocarpine).q
Whatqinstructionqshouldqtheqnurseqplanqtoqincludeqinqthisqclient’sqteaching?qA
A) “Doq notqallowq theqdropperq bottleq toq touchqtheq eye.”
B) “Administerqtheqmedicationqdirectlyqonqtheqcornea.”
C) “Squeezeq yourq eyeq closedq afterq administeringq theq drops.”
D) “Washqyourqhandsqafterqeachqadministrationqofqeyeqdrops.”
Whenqassessingqaqclientqwhoqstartsqtoqwheezeqrelatedqdataqshouldqobtain?qD
A) Presenceqofqradiation.
B) Heartqsounds.
C) Bodyqtemperature.
D) Precipitatingqfactors.
Theqhomeqhealthqnurseqisqreviewingqtheqpersonalqcareqofqanqelderlyqclientqwhoqlivesqalone.qWhic
hqclientqassessmentqfindingsqindicateqtheqneedqtoqassignqanqunlicensedqassistiveqpersonnel?q(UA
P)qtoqprovideqroutineqfootqcareqandqfileqtheclient’sqtoenails?qSelectqallqthatqapply.)qABC
A) Syncopeqwhenqbending.
B) Handqtremors.
C) Diminishedq visualq acuity.
D) Urinaryq incontinence.
E) Shufflingqgait.
Aqclientqisqdischargedqtoqaqlong-
termq careq facilityq withq anq indwellingqurinaryq catheter.qWhichqnursingqactionqshouldqbeincl
udedqinqtheqplanqtoqreduceqtheqclient’sqriskqforqinfectionqrelatedqtoqtheqcatheter?qB
A) Flushqtheqcatheterqdailyqwithq
sterileqsaline.
B) Encourageqincreasedqintakeqofqoralq
fluids.
, C) AdministerqaqPRNqantipyreticqifqaqfeverqdevelops.
D) Secureqtheqdrainageqbagqatqbladderqlevelqduringqtransport.
Toqassessqtheqqualityqofqanqadultqclient’sqpain,qwhatqapproachqshouldqtheqnursequse? C
A) Observeqbodyqlanguageqandqmovement.
B) Provideqaqnumericqpainqscale.
C) Askqtheqclientqtoqdescribeqtheqpain.
D) Identifyqeffectiveqpainqreliefqmeasures.
Aqclientqwhoqhasqbeenqdiagnosedqwithqterminalqcancerqtellsqtheqnurse,q“TheqdoctorqtoldqmeqIqhaveqc
ancerqandqdoqnotqhaveqlongtoqlive.”qWhichqresponseqisqbestqforqtheqnurseqtoqprovide?
A) “That’sqcorrect,qyouqdoqnotqhaveqlongqtoqlive” D
B) “Wouldqyouqlikeqmeqtoqcallqyourqminister?”
C) “Don'tqgivequp,qyouqstillqhaveq
chemotherapyqtoqtry.”
D) “Yes,qyourqconditionqisqserious.”
Whenq performingq bloodq pressureq measurementq toq assessq forq orthostaticq hypotension,q
whichqactionqshouldqtheqnurseimplementqfirst? C
A) Applyqtheqbloodqpressureqcuffqsecurely.
B) Recordqtheqclient’sqpulseqrateqandq
rhythm.
C) Positionqtheqclientqsupineqforqaqfewq
minutes.
D) Assistqtheq clientqtoq standq atqbedside.
Aqfemalequnlicensedqassistiveqpersonnelq(UAP)qisqassignedqtoqtakeqtheqvitalqsignsqofqaqclientqwithqpertussisq
forqwhomqdropletqprecautionsqhaveqbeenqimplemented.qTheqUAPqrequestqaqchangeqinqassignment,qstatingq
sheqhasqnotqyetqbeenqfittedqforaqparticulateqfilterqmask.qWhatqactionqshouldqtheqnurseqtake? D
q q q
AqpostoperativeqclientqhasqthreeqdifferentqPRNqanalgesicsqprescribedqforqdifferentqlevelsqofqpain.qT
heqnurseqinadvertentlyadministerqaqdoseqthatqisqnotqwithinqtheqprescribedqparameters.qWhatqact
ionqshouldqtheqnurseqtakeqfirst?q C
A) Determineqifqtheqpainqwasqrelieved.
B) Completeqaqmedicationqerrorqreport.
C) Assessqforq sideqeffectsq ofq theq medication.
D) Documentq theq client’sq responses.
Thequnlicensedqassistiveqpersonnelq(UAP)qdescribesqtheqappearanceqofqtheqbowelqmovem
entsqofqseveralqclients.qWhichqdescriptionsqwarrantqadditionalqfollow-
upqbyqtheqnurse?q(Selectqallqthatqapply.)ABDE
A) Multipleqhardqpellets.
B) Brownq liquid.
C) Formedqbutqsoft.
D) Solidqwithqredqstreaks
E) Tarryqappearance.
q
Anqelderlyqwomanqcomesqtoqtheqclinicqbecauseqofqvaginalqbleeding.qTheqhealthcareqproviderqfindsqaqvaginalqte
ar,qwhichqtheclientqreportsqisqlikelyqtoqhaveqoccurredqduringqunprotectedqsexualqintercourse.qWhichqcontentqisq
mostqimportantqforqtheqnurseqtoqincludeqinqthisqclient’sqteachingqplan? A
A) Theqimportanceq ofq usingq vaginalq lubricants.
B) Methodsqusedqtoqpracticeqsafeqsex.
C) Informationqaboutqalternativeqwaysqtoqexpressqsexuality.
D) Intercourseqpositionsqthatqhelpqpreventqtears.
Aqmaleq clientqhasqright-
sidedq hemiplegiaqfollowingq aq leftqcerebrovascularq accidentq(CVA).qHisqsittingqbalanceqhasqimpro
ved,qandqheqisqnowqableqtoqsitqinqaqwheelchair.qToqassistqtheqclientqin
, transferringqfromqtheqbedqtoqaqwheelchair,qwhatqactionqshouldtheqnurseqtake?
A) Haveqtheqclientqputqbothqarmsqaroundqtheqnurse’sqneckqforqsupport
B) Placetheqwheelchairqonqtheqclient’sqleftqside.
C) Instructqtheqclientqtoqlookqatqhisqfeet.
D) Instructqtheqclientqtotalqslow,qdeepqbreathsqwhileqtransferring.
Theqnurseqobservesqaqnewlyqadmittedqolderqadultqfemaleqtakeqshortqstepsqandqwalkqveryqslow
lyqwhileqpushingqaq walkerqinfrontqofqher.qWhatqactionqshouldqtheqnurseqtakeqinqresponseqtoqth
eseqobservations? A
A) Completeqaqfullqfallqriskqassessmentqofqtheqclient.
B) Teachq theqclientq toq takeq longerq stepsq atq fasterq pace.
C) Suggestqthatqtheqclientquseqaqwheelchairqinsteadqofqaqwalker.
D) Placeqclientqonqbedqrestquntilqtheqhealthcareqproviderqisqnotified.
Aqclientqisqreceivingqketorolacq(Toradol)qIMq45qmgqIMq6qhoursqforqpostoperativeqpain.qTheqavaila
bleq2qmlqvialqisqlabeled,ToradolqIMq30qmg/ml,qhowqmanyq shouldq theqnurseqadminister?q(Roundqt
oqtheqnearestqtenth.)q 1.5mg
Whileqsuctioningqaqclient’sqnasopharynx,qtheqnurseqobservesqthatqtheqclient’sqoxygenq
saturationqremainsqatq94%,qwhichqisqtheqsameqreadingqobtainedqpriorqtoqstartingqtheq
procedure.qWhatqactionqshouldqtheqnurseqtakeqinq responseqtoqthisqfinding?qC
A) Repositionqtheqpulseqoximeterqclipqtoqobtainqaqnewqreading.
B) Stopqsuctioningquntilqtheqpulseqoximeterqreadingqisqaboveq95%.
C) Completeqtheqintermittentqsuctionqofqtheqnasopharynx.
D) Applyqanqoxygenqmaskqoverqtheqclient’sqnoseqandqmouth.
Anqolderqwomanqwithqendqstageqheartqdiseaseqisqhospitalizedqforqsevereqheartqfailure.qSheqisqalert,qoriented,q
andqrequestsqthatnoqheroicqmeasuresqareqimplementedqifqherqbreathingqstops.qWhatqactionqshouldqtheqnur
seqtakeq first?qA
A) Discussqwithqtheqclientqherqmeaningqofqheroicqmeasures.
B) Obtainqaq“doqnotqresuscitate”q(DNR)qprescription.
, C) Setqupqaqfamilyqconferenceqtoqdiscussqtheqclient’s.
D) Consultqtheqpalliativeqcareqteamqaboutqclient’sqcare.
Aqclientqdiagnosedqwithqprimaryqopen-
angleqglaucomaqreceivedq aq prescriptionqforqbioticqeyeqdrops,qpilocarpineHCl(Pilocarpine).q
Whatqinstructionqshouldqtheqnurseqplanqtoqincludeqinqthisqclient’sqteaching?qA
A) “Doq notqallowq theqdropperq bottleq toq touchqtheq eye.”
B) “Administerqtheqmedicationqdirectlyqonqtheqcornea.”
C) “Squeezeq yourq eyeq closedq afterq administeringq theq drops.”
D) “Washqyourqhandsqafterqeachqadministrationqofqeyeqdrops.”
Whenqassessingqaqclientqwhoqstartsqtoqwheezeqrelatedqdataqshouldqobtain?qD
A) Presenceqofqradiation.
B) Heartqsounds.
C) Bodyqtemperature.
D) Precipitatingqfactors.
Theqhomeqhealthqnurseqisqreviewingqtheqpersonalqcareqofqanqelderlyqclientqwhoqlivesqalone.qWhic
hqclientqassessmentqfindingsqindicateqtheqneedqtoqassignqanqunlicensedqassistiveqpersonnel?q(UA
P)qtoqprovideqroutineqfootqcareqandqfileqtheclient’sqtoenails?qSelectqallqthatqapply.)qABC
A) Syncopeqwhenqbending.
B) Handqtremors.
C) Diminishedq visualq acuity.
D) Urinaryq incontinence.
E) Shufflingqgait.
Aqclientqisqdischargedqtoqaqlong-
termq careq facilityq withq anq indwellingqurinaryq catheter.qWhichqnursingqactionqshouldqbeincl
udedqinqtheqplanqtoqreduceqtheqclient’sqriskqforqinfectionqrelatedqtoqtheqcatheter?qB
A) Flushqtheqcatheterqdailyqwithq
sterileqsaline.
B) Encourageqincreasedqintakeqofqoralq
fluids.
, C) AdministerqaqPRNqantipyreticqifqaqfeverqdevelops.
D) Secureqtheqdrainageqbagqatqbladderqlevelqduringqtransport.
Toqassessqtheqqualityqofqanqadultqclient’sqpain,qwhatqapproachqshouldqtheqnursequse? C
A) Observeqbodyqlanguageqandqmovement.
B) Provideqaqnumericqpainqscale.
C) Askqtheqclientqtoqdescribeqtheqpain.
D) Identifyqeffectiveqpainqreliefqmeasures.
Aqclientqwhoqhasqbeenqdiagnosedqwithqterminalqcancerqtellsqtheqnurse,q“TheqdoctorqtoldqmeqIqhaveqc
ancerqandqdoqnotqhaveqlongtoqlive.”qWhichqresponseqisqbestqforqtheqnurseqtoqprovide?
A) “That’sqcorrect,qyouqdoqnotqhaveqlongqtoqlive” D
B) “Wouldqyouqlikeqmeqtoqcallqyourqminister?”
C) “Don'tqgivequp,qyouqstillqhaveq
chemotherapyqtoqtry.”
D) “Yes,qyourqconditionqisqserious.”
Whenq performingq bloodq pressureq measurementq toq assessq forq orthostaticq hypotension,q
whichqactionqshouldqtheqnurseimplementqfirst? C
A) Applyqtheqbloodqpressureqcuffqsecurely.
B) Recordqtheqclient’sqpulseqrateqandq
rhythm.
C) Positionqtheqclientqsupineqforqaqfewq
minutes.
D) Assistqtheq clientqtoq standq atqbedside.
Aqfemalequnlicensedqassistiveqpersonnelq(UAP)qisqassignedqtoqtakeqtheqvitalqsignsqofqaqclientqwithqpertussisq
forqwhomqdropletqprecautionsqhaveqbeenqimplemented.qTheqUAPqrequestqaqchangeqinqassignment,qstatingq
sheqhasqnotqyetqbeenqfittedqforaqparticulateqfilterqmask.qWhatqactionqshouldqtheqnurseqtake? D
